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The La.ycet, 

July 4 , 1908 . 


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THE LANCET, January 4, 1908. 

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Delivered to the Students of the London Hospital 

By ARTHUR KEITH, M.D. Aberd., 
j F.R.C.S. Eng., 


Gentlemen, —In the opinion of the great majority of 
medical men the subject of human anatomy, so far as it can 
serve the purposes of the physician and surgeon, has become 
in our time as perfect as the skill of man can make it. I 
trill not venture to say that such an opinion is unreasonable. 
The human body is a comparatively small and strictly 
circumscribed field wherein generation after generation of 
anatomists have laboured during many centuries, treasuring 
and perpetuating their observations in an almost endless 
■series of tomes. If finality be possible we ought now to 
have reached it. One who believes that the stage of per¬ 
fection has been reached might cite onr modern teat-books 
of anatomy as evidence ; they seem to leave nothing further 
to be desired ; their bulk ought to betoken finality. Never 
before has the structure of the body been displayed so 
exhaustively, so accurately, or so temptingly as to the young 
man who commences the study of medicine to-day. But 
unfortunately the condition of a subject, its perfection or 
imperfection, cannot be measured by an examination of its 
text books. As regards human anatomy it can be judged 
only by seeing how well it serves the needs of medical men, 
and when modern anatomy is measured by this standard it 
seems to me to fall very far short of perfection. 

To make my meaning clear, let me cite a number of 
structures on which anatomists, physicians, and especially 
surgeons have concentrated their most strenuous endeavours 
during the last two or three decades. I will Belect the 
appendix vermiformis as my first instance. Its size, shape, 
position, variations, and development are described in the 
most elaborate detail, but nowhere can one find answers to 
these questions : Why is its lumen so small, its muscular 
coat so thick, and its supply of lymphoid tissue so abundant ? 
Why does it, like the thymus, tonsil, Peyer’s patches, and 
lymphoid structures generally tend to undergo an atrophy 
with age 1 Yet the answers to these questions seem to me 
to constitute the very essence of the anatomy of the 
appendix. Could the anatomist answer these, then indeed 
we should know something of its nature. To call the 
appendix a “vestigial structure” or a “cseoal tonsil” is 
merely a manner of covering our ignorance of its nature by 
a gloss of knowledge— a very remarkable thing in the case of 
a structure that causes the death of thousands of persons. 
The great intestine will serve as another instance. It has 
been most minutely described and demarcated into segments; 
its fixation, its taeniae, its form, and course are set forth in 
our text-books at great length. But no one asks why it is so 
placed and fixed, why its outer muscular coat is grouped in 
ticoim, or why it takes such a remarkable and tortuous 
course. Certainly the theory of its being a useless structure 
and a cesspool, promulgated by MetchDikoff and accepted bv 
so many, will not assist us in explaining the signifi- ance of 
these features. Many other structures might be cited, such 
as the gall-bladder, the prostate, the epididymis, the antrum 
of the mastoid, the nasal air sinuses, the semilunar cartilages 
of the knee, the erector spime, or the folds and arrangement 
of the peritoneum. On each one of these structures 
anatomists and surgeons have focussed their attention of late 
yetrs with the result that we have accumulated an enormous 
catalogue of their physical characters, but of their nature, 
meaning, or function little or nothing. That a generation of 
medical men in seeking to establish a scientific basis on 
which to apply treatment should rest content with merely 
describing the physical characters of parts which are so 
often the seat-of disease seems to me a very remarkable 
defect in our modem methods of anatomical inquiry. This 
grave defect I believe to be a direct result of the modern 
conception of human anatomy. 

What is our modern conception of human anatomy 1 If 

No. 4401. 

you turn to examination papers you will find it; most of the 
questions begin with the word “describe.” Turn to onr 
text-books and you will find that such aDd such a part 
“ presents for description or examination the following 
features ” as if the main reason for the very existence of the 
pait was for “the purposes of description.” Our anatomical 
text-books are what they claim to be—works on “descrip¬ 
tive ” anatomy. The art of description has become the 
chief purpose of aDatomy. We describe to you the heart in 
its utmost details—its shape, surfaces, borders, and grooves; 
we treat it as a still-life study, a thing of crests and angles 
so utterly unlike the palpitating oigan you afterwards have 
to place your stethoscope ever that you cannot imagine the 
anatomical and clinical heart to be the same thing. In my 
student days two books on anatomy were held up for 
particular commendation; one was Ward’s “Osteology,” 
the other Ellis's “Anatomy” (now in my opinion much 
improved). Both are magnificent examples of accurate and 
painstaking observation and description. If aDatomy be but 
the correct description of parts, then, indeed, onr subject has 
leached a finality. To my mind the apparent futility and 
barrenness which characterise so much of our modern 
anatomical work are due to the fact that this descriptive 
ideal has been accepted and that the business oi the 
anatomist is to describe appearances, not to explaiD them. 

The remarkable story of bow anatomy came to he 
regarded in England as a “descriptive science” com¬ 
mences towards the close of the eighteenth century. In 
the latter part of that century British anatomists were, as 
indeed they had always been, much more than mere 
descrlbers. John Hunter in London and Alexander Monro 
(seonndus) in Edinburgh had modelled themselves on the 
prototype o< English anatomists, William Harvey. In no 
sense was Harvey a descriptive anatomist: he studied the 
human body to understand the significance, not the form of 
the various parts. He peiceived that the hypotheses ot his 
time did not account for the structure of the heart nor for 
the arrangement of its blood-vessels. It was to explain 
these that he postulated the theory of the circulation ot the 
blood, the truth of which he afterwards proved by experi¬ 
ment. It was in the same spirit that Hunter. Monro, aDd the 
two Beils pursued the study of anatomy in England in the 
later decades of the eighteenth century. To Hunter the 
observation of a fact was bnt the prelude to an attempt 
to explain its significance. It was not enough to record 
that the wall of the aorta was twice as thick as that of the 
pulmonary artery or that the walls of some veins were thick 
and of others thin : he immediately set to work to find ont 
the significance of these facts ; he appealed to comparative 
anatomy, to embryology, to pathology, and experiment for 
an explanation. Monro formed a true conception of the 
manner in which the cerebral circulation was carried on from 
a consideration of the anatomy of the parts; he did not rest 
content with merely describing the venous sinuses within the 
skull but sought for the reason why the larger intracranial 
veins assume such a peculiar form. In the “System of 
Dissections” by Charles Bell, 1 and in the text-book first 
issued in 1793 by John and Charles Bell, one sees the same 
spirit at work. Thus, up to the end of the eighteenth 
ceDtury there was a strong Bchool of British anatomists who 
regarded dissecting as a means for obtaining not a descrip¬ 
tion but an understanding of the human body. By the end 
of the second decade of the nineteenth century this robust 
British school had almost ceased to exist, its extinction 
being due to the introduction of a French fashiOD. At that 
time our young men turned to Paris for their meoical ideals, 
just as now our young women seek there the standard of 
fashion. Our young anatomists preferred the clear, 
methodical descriptive manner of the Parisian school to the 
heavier methods of their predecessors. Dercriptive anatomy 
had thriven amazingly in the French schools. It. was the 
creation, 1 think, of the famous Winslow, professor of 
aDatomy, physic, and surgery iu the University of Paris, in 
the middle decades of the eighteenth century. He had 
(hut to a very high degree) that gift which many of his 
countrymen still retain of engaging the rapt attention 
of his readers and hearers by the sheer lucidity and 
orderliness of his descriptions. While merely conveying to 
his hearers or readers what they might see with their own 
eyes at a glance be left with them the pleasant impression 
that they were drinking at the very fountain-head of pure 
knowledge. This special gift of vivid de-cription has olten 

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I ~£ 1 Edinburgh, 1798. 


deluded scholars into mistaking the shadow for the sab- 
stance. A sjstem of knowledge which settles home too 
easily in one’s understanding is jnst the knowledge to be 
accepted with scrutiny. Winslow purposely abstained from 
attempting to explain the meaning of the structures which 
he described, proposing to relegate all that related to func¬ 
tion to another volume. In so doing he emasculated anatomy ; 
but the system he initiated prospered abundantly, and at the 
end of the eighteenth century, in the hands of his able 
follower Bichat, it came to be regarded, in France at least, 
as the ideal conception of anatomy. 

In the opening years of the nineteenth century we can see 
the French influence at work in the British schools. In 1804 
and 1807 appeared Sir Astley Cooper's famous folios on Hernia. 
They differ totally in spirit from the anatomical works of the 
previous age—those of Hunter and Monro. They are minute, 
elaborate, and rather irksomely accurate descriptions of 
parts ; he never stops to ask why the parts are so arranged 
but is content to have described them. The “ London 
Dissector,” a popular guide in the dissecting-room during 
the earlier part of last century, is a purely descriptive work 
with the merit of brevity. The “ Dublin Dissector ” is un- 
mistakeably founded on the teaching of Bichat. When in 
1828 Jones Quain published the first edition of that famous 
work, which has had many rivals but, in my opinion, 
no equal, be quotes with commendation the system of 
description enunciated by BOclard—namely, that in deal¬ 
ing with a Btrncture the following order should be ob¬ 
served : (1) form and outline ; (2) situation and relationship ; 
(3) direction of its axis; (4) size ; [5) physical characters; 
(6) anatomical composition ; (7) chemical composition; 
(8) secretions ; (9) properties duriDg life ; (10) vital action ; 
(11) sex and age change ; and (12) morbid changes. 
Bedard’s is certainly a comprehensive formula, but still it 
is a formula, and nothing is more certain than that the intro¬ 
duction of a formula into any system of knowledge whatso¬ 
ever means a cessation of all rational endeavour in that 
system. But to see with what avidity the conception of 
anatomy as a “descriptive science” was accepted in Britain 
one must turn to the writings of that ill-starred whirlwind, 
the brilliant anatomical demagogue, Robert Knox of Edin¬ 
burgh. It seized him with all the force of a revelation; in 
season and out of season, by translation of French treatises 
and popular lectures, he preached the adoption of the 
methods and ideals of Bichat and Cuvier as the salvation 
of British anatomy. If other British anatomists adopted these 
ideals more quietly than Knox they were nevertheless sound 
converts and by the middle of the nineteenth century we see 
the French formularies bronght to perfection in the hands 
of Ward and Ellis. Throughout the whole of the nineteenth 
century British anatomists built on the plan designed by the 
French anatomists of the eighteenth century. That this plan 
has provided a sound foundation for the accumulation and 
systematisation of anatomical fact no one can deny who is 
familiar with our magnificent modern text-books, wherein, at 
a length of some 800,000 or 900,000 words, the medical 
student is presented with an exhaustive description of the 
dead, human body. If we had remained true to the ideals of 
the earlier British anatomists they would have portrayed a 
picture of the living human body. 

While the general trend of anatomy in this country during 
the nineteenth century was mainly determined by the accep 
tance of the French ideals, yet even a brief account would 
be altogether misleading unless other influences are noted 
which came to bear on British anatomists and determim d 
the direction of their observations. In the opening decades 
of the nineteenth century Cuvier’s influence was profound. 
He had demonstrated to all the world that anatomy pro¬ 
vided the data by which the members of the animal kingdom 
might be arranged in a natural and orderly system of groups. 
Anatomy, which had been the humble utilitarian drudge of 
medical men, was promoted to be the handmaid of men whose 
aim was pure science. Human anatomists gladly forsook the 
task of trying to discover the mechanism of the human body 
and Bet out on the high task of setting the animal kingdom in 
order. The methods of descriptive anatomy, however 
imperfectly they may answer the purposes of medical men, 
were admirably adapted for the needs of the comparative 
anatomist. Owen became the first effective exponent of the 
Cuvierian school in England and I know of no finer irony in 
fate than that the Hunterian collection which the eighteenth 
century master had built up to elucidate tbe contrivance of 
the human body in particular and the organisation of living 
things in general, should have been placed in the hands of 

one who, however brilliant his powers of description, was a 
believer in archetypes rather than in function. Owen’s fame 
and name were great, and if he exercised no direct effect on 
the body of knowledge which we call human anatomy, yet 
one can see that from 1830 onwards he gave many anatomists 
a bent towards vertebrate morphology, and thus to some 
degree modified the undercurrent of our anatomical text. 

There is a very remarkable parallelism between the three 
men who dominated anatomical work in France during the 
earlier decades of the nineteenth century and the three men 
who exercised a similar influence in England during the gre .t 
Victorian period. Cuvier was accompanied by two men, 
Etienne Geoffrey St. Hilaire and Lamarck. They were 
interpreters of fact, and Cuvier, a describer and classifier,used 
his predominating influence to suppress them. Owen was also 
accompanied by two interpreters of fact; in place of Geoffrey 
St Hilaire stands Huxley, in place of Lamarok, Darwin, but 
in England it was the interpreters of fact who proved 
victorious. Darwin and Huxley had a profound influence on 
the work of British anatomists ; they brought them back to 
the study of the human body ; evolution provided a key to 
many structures which puzzled the human anatomist. But 
while man's position in the animal world was being deter¬ 
mined with great success his place in the medical world was 
well-nigh forgotten. 

In the last three decades of the nineteenth century a 
movement in a new direction became general amongst ana¬ 
tomists. The development of the body became more and more 
a subject of investigation. In this movement the late 
Professor His exercised a predominating influence; it was 
patent to all that the reconstructional and modelling methods 
which he employed with consummate skill provided the 
material for the foundation of a sound and progressive 
system of knowledge. In the main His was a descriptive 
embryologist; he carried the ideals current amongst 
anatomists of his time into a new field of work. Far be it 
from me to deprecate the value of descriptive work in 
embryology or anatomy ; only I would most strenuously urge, 
what is so frequently forgotten, that description is only the 
beginning, not the end, of all embryological and anatomical 

Thus it comes to pass that a young mac commencing the 
study of medicine in 1907, although he may obtain a truer 
conception of “ Man’s Place in Nature” and a fuller know¬ 
ledge of the development of the human body than was 
possible for his predecessor of 1807, yet holds little or no 
advantage over him as regards the available stock of practical 
anatomical knowledge. For proof of what I maintain one 
may turn to the account of the heart, that organ which in 
all times has been accounted the moBt important in the 
study and practice of medicine, given in Bichat’s “ Trait 6 
d’Anatomie Descriptive” 3 and compare it with the descrip¬ 
tions given in the latest editions of our modern text-book of 
anatomy and it will be found that, as far as concerns the 
caked eve anatomy of the heart, the one account differs very 
little from the other; indeed, if anything, the older book 
gives the better working picture of the heart. The same 
parts are enumerated and described ; in the right auricle, 
for instance, the student is asked to observe the openings of 
the superior and inferior vena cava, but in neither the old 
work nor the new is any mention made of the arrangement 
of the musculature round these orifices, the student appa¬ 
rently being expected to presume that they are always open. 
Bichat, it is true, describes a rounded band of musculature 
in the right auricle crossing in front of the superior caval 
orifice but of its significance says nothing. In modern text¬ 
books this same hand is described as a crest—the crista 
terminalis, the very came showing how far anatomists 
have lost sight of function when they name a contracting 
band of muscle a crest. From the physiologist the modern 
student learns that these orifices are closed during auricular 
systole by the surrounding circular musculature, but when 
he comes to examine the human heart he will find that there 
is no circular musculature round the inferior caval orifice, 
while he will find it difficult to believe that the muscle 
round the upper orifice is sufficient for the task ascribed 
to it. 

Having compared the best of the early nineteenth 
century with the best of the early twentieth century 
anatomies, let us turn to the account in the last of the 
truly British text-books, Bells’ “Anatomy of the Human 
Body.” From an examination of the parts the anatomist 

a Paris, 1803. 

Thb Lancet,] 


there infers that neither orifice can be closed ; that they are 
always open, in systole and diastole ; and that regurgitation 
of blood duriDg the contraction of the auricle is prevented 
by the pressure in the veins being normally greater than 
the diastolic pressure in the right ventricle. I am now 
convinced that, as far as concerns the inferior caval orifice, 
John Bell’s conception is true, and I am not so certain 
as I was that the band of muscle above mentioned—the 
tienia terminalis—is absolutely sufficient to occlude the 
upper orifice in man, although there can be no doubt from 
its arrangement that it does diminish it in auricular syBtole. 
Within the right auricle, too, turning again to modern 
text-books, the student is expected to examine the tubercle 
of Lower which is believed to direct the current of blood 
flowing in from the inferior vena cava—a miniature break¬ 
water. Bichat expresses a doubt as to the tubercle ; he 
speaks of it as the “ tubercle which Lower saw or believed 
he saw.” Bell expresses a more definite doubt. “It is 
commonly absent," he states, and adds “ if it were not really 
an imagination of that celebrated anatomist.” Now, what 
Lower represents in the figure showing this “tubercle" is 
the heart of the calf or sheep, in which the upper and lower 
venae cavae enter the right auricle close together and set at a 
fairly acute angle to each other, so that the band of muscle 
between their orifices is very apparent on the interior of the 
auricle. It was to this intercaval band of muscle which 
Lower gave the name of tubercle, a term inappropriate in 
the sheep’s heart and altogether inapplicable to the human 

Many farther instances might be cited to show how far the 
adoption of the descriptive method has obscured our real 
object in studying the anatomy of the heart. I will refer to 
only one—namely, the structures concerned in tricuspid re¬ 
gurgitation All of us who now teach human anatomy must 
have been familiar as students with the clinical doctrine that 
under certain conditions the tricuspid valve became incom¬ 
petent. Yet, in our published descriptions we never ask the 
student to look beyond the cusps of the valve and the fibrous 
ring—a very delicate ring it is—which surrounds the orifice 
as the means of securing competency. The relationship of 
the musculature at the base of the right ventricle to this 
orifice and the effect of its contraction on the size of the 
orifice were scarcely mentioned, yet from a clinical point of 
view the surrounding musculature is infinitely more import¬ 
ant than the surrounding fibrous ring. In spite of the 
teaching and discoveries of embryology we still confuse 
under the term “base” two totaily different parts of the 
heart—namely, the commencement and end of the cardiac 
tube. The conical shape of the heart—its apex and base— 
we assume as axiomatic and incapable of explanation. We 
describe the walls of its chambers as if they were rigid, over¬ 
looking the fact that they are composed of a pulsating 
musculature arranged so as to produce definite movements 
by which their contents are propelled. 

So far my argument has been to show that our progress in 
real practical human anatomy during the nineteenth century 
has not been so great as is generally supposed, the lack of 
progress being due in the fir-t place to our acceptation of 
"descriptive” anatomy as the real anatomy, and, in the 
second place, becau-e side issues have been allowed to draw 
anatomists away from their real work. But it might be 
urged that the defects I see in modern anatomy are the 
result of the separation from it of physiology—a separation 
necessitated hy the growth of knowledge. That a separation 
was necessary I fully admit, but that the dividing line should 
have been drawn where we now find it has proved, as I have 
just shown, a great misfortune, not only for the progress of 
anatomy but also of physiology. It is an artificial line 
established hy Winslow's unhappy facility of description. 
Between anatomy and physiology has been left a no man’s 
land and yet one of great importance to medical men. I 
refer especially to the muscular mechanisms of the body— 
the mechanism of respiration, circulation, digestion, 
deglutition, micturition, and locomotion, subjects at present 
indifferently taught and indifferently understood, because the 
man who teache- the action has forgotten the structures that 
are involve*', and the man who describes and knows the 
Structures has not tronhled to discover how they act. In our 
school, as in many others throughout the country, the gap 
Between anatomy and j histology, whioh tends to widen, has 
not been felt because of trie harmonious workings of the two 
departments, yet I think the time has come when a recon¬ 
sideration of i h« present dividing line is necessary in the 
interests of ail concerned. 

There are many reasons that make a reconsideration of the 
present scope of anatomy urgent. There is, in the first 
place, the enormous growth of physiology ; already those 
that teach that subject find its present scope beyond the 
powers of one teacher. There is, in the second place, the 
necessity of finding more time for the subjects absolutely 
essential to the profession of medicine—the old but ever¬ 
growing subjects of medicine, surgery, and midwifery : the 
newer subjects—pathology, bacteriology, pharmacology, 
hygiene, and special diseases. Something has to be unloaded 
to make proper room for those, and we anatomists, who 
like thrifty housewives have treasured everything, have to 
unload our share and, for my part, I will willingly let go 
much of that material we dragged ashore in our close-meshed 
descriptive net. If to the Bplendid basis of descriptive 
anatomy we have now at our disposal we were to add the 
practical spirit of the eighteenth century anatomists I feel 
certain we should secure a future of great prosperity for 



Delivered at King't College , London, 



Gentlemen, —It may be a commonplace remark, but it is 
nevertheless true, that in tracing the evolution of the present 
state of knowledge of any subject one engages in a task which 
is at once illuminating and stimulating. How interesting it 
is, for example, to come across such observations as those of 
Rathke and Valentin, two distinguished men who lived in 
the first half of the last century and who clearly saw the 
great future which lay before the science of embryology. 
Thus Rathke, in 1832, commences his anatomical and philo¬ 
sophical researches, &c., with a praise of our subject: “In 
order to understand the laws which lie at the foundation of 
animal creation,” he says, “one must not look only at the 
fully-developed animal but also turn attention to those in 
process of development. For here yon see an organ gradually 
converted from a simple into a complex one. Moreover, it 
stands to reason that one is able to recognise the laws of 
creation sooner whilst they are actually being carried on 
than when they are completed.” And Valentin, in 1835, 
remarks : “ Almost all physiologists and anatomists who 
have been active and celebrated in onr time have directed 
their attentions to the development of the individual as 
opposed to the problem of the relationships of the animal 
world—i.e., comparative anatomy. Both together are tbe 
foundation on which the true and genuine conception of 
animal life must be based.” 

In tracing the history of embryology we see that although 
the study of the actual development of animals daring their 
evolution from the egg has attracted attention from very 
early times, little advance was made until comparatively 
recent years. Indeed, it is only within the last 20 or 30 
years that the enormouB powers of embryology as an instru¬ 
ment for unravelling the problems of early growth have been 
manifest, and one can clearly see the main factors which 
have contributed to this change of affairs : the promulga¬ 
tion of the cell theory, the invention of the microtome, 
Darwin’s theory of the origin of species, and lastly the 
many observers who, with modern weapons, have explored 
the little-known country hitherto visited by a small but 
valiant band. 

Striking, therefore, as were the advances made in all 
branches of biological inquiry during the nineteenth century, 
in few was this advance more marked than in that of 
embryology. From its commencement, through the genius 
of Harvey, Haller, and Wolff in the seventeenth and 
eighteenth centuries, little progress was made until the early 
years of the nineteenth century, which through the-researches 
of Pander and von Baer practically witnessed the birth of 
embryology as a science. Pander's investigations have 
become classical and the results of his work are to be found 
in our modern text-books of embryology and are taught 
to-day. Through the interest thus associated with Pander 
and his time it may be recalled that it was in 1817 that he 


and toc Baer proceeded to Wurzburg to work nnder 
Ddllinger, and as a result of his advice and influence 
Pander carried out important researches on the develop¬ 
ment of the chick. Thus was formed, as von Baer him¬ 
self has told us, a noteworthy association, destined to 
have far-reaching results, between Dollinger, the grey¬ 
haired veteran in physiological researches, the youthful 
Pander, burning with zeal for science, and the incomparable 
artist Dalton. Von’Baer was so impressed with Pander's 
zeal that he, too, determined to devote himself to the 
pursuit of embryological problems. In 1819 he proceeded to 
Kooigsberg, and for several years enthusiastically applied 
himself to the elucidation of the developmental phenomena 
of animal organisms. The first volume embodying the remits 
of the monumental work was published in 1828, entitled 
“ Observations and Reflections on the Development of 
Animals.” The second volume was published in 1837, and a 
third one in 1888, after his death. These publications 
contain cot only the main results of Baer’s scientific inquiries 
but also form the basis on which all modern embryology 
practically rests. Referring to them, Huxley justly 
observes: “Baer’s book on the development of animals 
contains the deepest and soundest philosophy of biology and 
zoology which has ever been presented to the world,” and 
Kolliker is in agreement with him when he says “ Baer's 
works ought, on account of their richness and excellence of 
faots, the erndition and the magnitude of the developmental 
observations, certainly to be regarded as the best which the 
embryological literature of all times and all nations has to 
show.” Amongst Baer's observations one stands supreme— 
viz., the finding of the mammalian ovum in 1827. This 
discovery was published in a short pamphlet entitled “ De 
Ovi Mammalium et Hominis Genesi,”and he subsequently 
demonstrated before a society of natural philosophy in Berlin 
preparations showing the extremely small mammalian ovum 
inclosed within the Graafian follicle. 

But besides von Baer, to whom must be ascribed the first 
place amongst the workers in embryological science, many 
others were engaged abont this time in similar problems in 
Germany and other countries. In Germany, Oken and 
Meckel, Oarus and Rathke, Johannes Muller, Huschke, and 
Siebold ; in France, Butrochet, Provost, and Coste ; in 
England, Allen Thomson, Wharton Jones, and Martin 
Barry; in Italy, the famous Rusconi—each made valuable 
contributions to the rapidly growing science. 

Here let me say a few words about Allen Thomson, 
whose son we have amongst us as Vice Principal of this 
College. He is rightly regarded as the father of embryology 
in this country. He published as early as 1839 papers dealing 
with early human embryos, and even before this date—i.e., 
in 1831—he proved by means of sections cut by hand that 
the main aorta is formed by the median fusion of two vessels 
previously separate, a most interesting and noteworthy dis¬ 
covery. Moreover, we ought not to forget that prior to 1830 
little was known of embryological science in this country and 
that between 1830 and 1845 the only anatomist who was 
devoting himself to human embryology was Allen Thomson 
and that it was in this field that he won his laurels. It is an 
interesting fact and shows the bent of his mind that at 
21 years of age he published a paper on the development of 
the vascular system, and throughout his life embryology 
continued to be the favourite subject of his study and 

N jw may I remind you that the work done in the field of 
embryology in the first half of the century was done before 
the discovery of the microtome, an instrument which, 
though universally used at the present day, is of compara¬ 
tively recent introduction. Indeed, so little advance had 
been made in methods of technique that Pander and von 
Baer practically used the same methods as Haller and Wolff 
had done in the century preceding. I gather from a paper 
by Professor Minot that “ sections, though more or less used 
in the early half of the century, were not much relied upon 
until the second half of the century had been reached, and 
we may say that it was approximately about 1860 that 
section cutting began to come in'o favour among micro- 
scopists. But it was not nntil 1874 that microtomes began 
to make their way.” How then did the old embryologists 
arrive at their conclusions ? An interesting sidelight is 
thrown on this question by Huschke mentioned above. This 
observer published in 1832 an account of the formation of 
the otic vesicle and the lens. As he studied the growth of 
the eye in the chick he noticed in the middle of the eye 
vesicle a little spot which he imagined to be the anlage of 

[Jan. 4, 1908. 

the lens. He explored it with a fine hair, with the point of— 
which he slipped into an opening. “Now I am free from a 
all doubts,” he says. “I knew at once how the lens, the 
lens capsnle, and particularly the labyrinth of the ear were:: 
developed. I saw they were formed from a depression or 
invagination of the external skin.” 

And so with snch simple apparatus as a magnifying lens, a 
scissors, knife, and razor the pioneers of embryology pursued 
their way. Then came the wonderful discovery of Schwann 
that ail animal tissues were composed of cells. With this 
new impetus it is not surprising to find that embryology was a 
for a time included as a branch of physiology. The delicate 
methods employed in histological research were just thoseu 
necessary for the study of young embryos and the subject 
was therefore taught by physiologists. But the anatomists 
soon woke up ; they saw a new world ready for exploration, 
a world which for them offered a solution of many completely 
unintelligible anatomical facts. It was therefore absolutely 
essential for them to master the new science and with as 
little delay as passible they entered into possession of their 
kingdom. Schwann's discovery ultimately had a trans¬ 
forming influence on embryological technique. The methods 
of the old teachers were no longer sufficient. It was re¬ 
cognised that what the atom was to the chemist the cell was 
to the embryologist, and nothing short of thin sections, high 
power of magnification, and elaborate methods of staining 
would suffice. It was imperative that there should be some 
means of obtaining thin even serial sections and this demand 
was soon supplied by the genius of His. 

The first microtome, the instrument by which serial 
sections of objects are obtained, which at all corresponded 
in principle to those in use at the present day is apparently e 
the one described by His in 1870. Previously to that time a 
form of microtome known as Valentin's double knife had 
been employed, but the principle of this was altogether 
different from that of the microtome in use now. The 
essential points of His's microtome were a mechanically : 
moved razor and an arrangement for mechanically advancing 
the block, and although the means of obtaining theseC 
essential points have in later years been improved they con¬ 
stitute the basis on wniob all microtomes are constructed. 

I think it may not be without interest to quote the 
following statement made by His, for nothing could better 
illustrate the enormous progress that has been made since 
1870. Professor His, speaking of the advantages of his own 
instrument, said: “I have used the instrument since 1866 
and I have prepared during this epoch (i.e., four years) over 
5000 sections.” My assistant Weston has recently cat, by 
means of a modern microtome, nearly 5000 serial sections in 
a fortnight in the odd intervals snatched during the day 
from the ordinary routine work of the department. 

Striking as was the work of Pander and von Baer in the-, 
earlier part of the century, in no less degree was that of 
Wilhelm His in later years. His influence on embryology 
has been incalculable, and if 1 were to mention particularly , 
one of his researches in preference to others, it would be the 
wonderful monument of neurological investigation, which 
stands unique. Indeed, so far-reaching has the influence 
of His's life been on all subsequent workers in the field of 
embryology that it may not be out of place to give a brief 
sketch of the career of this remarkable man. 

Wilhelm His was born in Basle in 1831 and it was there ti 
that he commenced his medical studies in 1849. In the year 
following be moved to Berne where he had some relatives 
connected with the university of that city. Here Thiele 
taught anatomy, Valentin physiology, and Bernard Studer 
geology. From 1850 to 1852 His was in Berlin, where he 
came under the influence of Johannes Muller and Remak. 
He was much impressed by the great biologist, whose lectures 
on human and comparative anatomy were at that time 
perhaps unequalled. Indeed, Professor His has left it on 
record that the first lecture of J. Muller which he attended 
was a perfect revelation in the way of teaching and erudition. 
It was, too, from Muller and Remak that he learnt the 
elements of embryology, and thus laid the foundation of the 
great work which he was destined to carry out in the future. 
From Berlin he went to Wurzburg, where he stayed three 
terms (1852-53) Here he came under the notice of Virchow 
and worked in his laboratories. Shortly afterwards, in 1854, 
he returned to Basle to complete his examinations and then 
he proceeded to Paris. In Paris he met Claude Bernard and 
Brown Sfiquard, and worked for >ome time in the laboratory 
of the Cull figi: de France. In 1857 be became a privat-docent 
under Professor Meissner, and in the same year, when only 

Thu Lancet,] 


26 years of age, he became, throngh Meissner’s promotion to 
1'reiborg, professor of anatomy and physiology in his native 
town. Owing to his youth and natural modesty, he was some¬ 
what diffident of bis power for carrying on the work of the 
two subjects, but the Chancellor of the University (Herr 
Peter Merian) remarked to him : “ Wir haben sie ins Wasser 
geworfen, sie mogen nunzusehen, wiesieechwimmen” (“We 
hate thrown you into the water, see to it that you now 
swim It is well known how brilliant his career has been 
ted how richly his labours have been rewarded in that realm 
of science over which he held almost sovereign sway. His 
has acknowledged, however, in allusion to the remark of the 
Chancellor that several times in the first year after 
his appointment, when day by day he was engaged 
in preparing lectures, demonstrations, and experiments, “Der 
Wasser ging mir allerdings weit an den Hals herauf,”or, in 
other words, that he often felt like drowniog. He remained 
in the University of Basle until 1872, when he succeeded 
E. H. Weber as professor of anatomy and director of the 
anatomical laboratories in the University of Leipsic. Simul¬ 
taneously with his appointment, VV. Braune, Weber’s son-in- 
law, became professor of topographical anatomy in the same 
University. These two men, differing in age by only a few 
days, but differing markedly in their general temperaments, 
became very close friends, and on the death of Braune in 
April, 1892. the loss was felt by His to be well-nigh irre¬ 
parable. Hls’s work was done first in the old, then in the 
new buildings of the institute at Leipsic. The new buildings 
were erected under bis supervision and have become a model 
for successive generations. With regard to his original 
work, it may be said at once that he contributed valuable 
papers to nearly every department of anatomy, but it is as 
an embryologist that he is best known in this country, where 
his name has been familiar to every medical student during 
the last 20 years. In 1885 he completed the great work 
which he published under the name of “ Anatomie Men- 
schlicher Embryonen ” and which has formed the basis of all 
subsequent text-books dealing with embryology. 11 m’s mono¬ 
graphs and miscellaneous papers exceed one hundred in 
number. He passed away in May, 1904, in his seventy-third 
year, the promise of his earlier days being amply fulfilled, 
and he has left a legacy of enormous scientific value to his 

To the medical student anatomy very often means simply 
human anatomy. But this is anatomy in a very restricted 
sense. Anatomy when regarded as a science includes embry 
ology and comparative anatomy, whilst anatomy essential to 
the physician and surgeon is really applied anatomy. The 
three subjects, human anatomy, comparative anatomy, and 
embryology, constitute what is known as morphology and the 
specialist in anatomy of to-day must be acquainted with all 
three. Similarly a well equipped anatomical institute must 
contain laboratories for the prosecution of research in these 
three directions. Moreover, in view of the supreme import¬ 
ance of a precise and accurate knowledge of the anatomy of 
the human body and the limited time for the study of the 
preliminary and intermediate subjects, it is not surprising 
that the medical student should have less regard for the 
study of embryology and comparative anatomy than for 
human anatomy. But practical embryology is a fine training 
for anyone who proposes to enter the medical profession, 
whether he intends to be a surgeon, a physician, or a general 
practitioner. The patience, skill, and thoroughness necessary 
to work successfully through an embryo train hie powers 
exactly in the right direction, and in some of the nniversities 
in Germany medical students who have the time and inclina¬ 
tion are encouraged to take up work of this class. 

We have seen how in the prosecution of embryological 
research serial sections became imperative. Odd sections 
taken here and there and studied apart instead of in con¬ 
junction with neighbouring sections could only lead to specu¬ 
lation and error. Even with a complete series of sections of an 
embryo it is oftendifficult to read them correctly ; it is there 
fore necessary to visualise them in some way and this is now 
done by reconstruction methods. If you will pardon the 
simile, it might be said that just aB by means of a piano the 
beauties of a piece of music in manuscript can be rendered 
manifest, so by reconstruction in wax, one can visualise and 
make manifest the form of the embryo from a series of 
microscopical sections. It is easier to appreciate music 
when it is actually played on an instrument and it is easier 
to interpret and appreciate microscopical sections of embryos 
when they are reconstructed in wax in the form of a model 
the employment of serial sections therefore leads naturally 

enough to the discovery of reconstruction methods. To 
Professor His must be given the credit of perceiving the 
need of reproducing in some way the bodily form of the 
object which had been cut into sections. This necessity he 
met by his “ projective reconstruction method.” May I 
describe this very briefly ! He employed millimetre paper, 
each line Of which was taken to represent a section. 
Beginning from a base line, the back in case of a profile 
reconstruction, and the middle line of the body in case of a 
frontal reconstruction, be measured along the lines of his 
paper the distances of any organ as shown in the drawings 
which he made of the sections enlarged, say, 100 times. 
When he had entirely worked throngh his series of sections 
the corresponding points on the lines were joined up, 
and thus was projected on paper the profile form of the 
object with which he was dealing magnified 100 times. 
After working through the sections of the embryo in this 
most exact way he set to work to freely model the embryo in 
Olay or wax. That is to say : he had obtained such a know¬ 
ledge of the embryo from working through the serial sections 
that he was able to take some clay and make a model of the 
form he conceived the embryo to be, controlling all the time 
the size and distances, &c., by means of callipers and refer¬ 
ences to the enlarged drawings of the sections. In this way 
many well-known models were made which have become 
familiar to all students of biology and anatomy throughout 
the world, and I would mention particularly the series of 
models illustrating the development of the chick, the salmon, 
and the human embryo. How necessary it was to visualise 
the sections in some such way as this is shown by the fact 
that Krieger quite independently thought out the same idea. 
He employed the same methods in the study of the central 
nervous system of the crab and about the same time, or a 
little later, other methods were suggested which served the 
same purpose. His's projective reconstruction furnished 
drawings and freely modelled objects. In the making of the 
models he has had no successor. The art required a par¬ 
ticularly high technical gift to overcome the many obstacles 
and to neutralise the many sources of error. Moreover, a 
new method was suggested by Professor Born which entirely 
displaced it. This was, after various modifications, eventu¬ 
ally extensively employed and was utilised by His himself in 
his later years. 

Before proceeding to give an account of Professor Born’s 
method of reconstruction by means of wax plates I wish to 
refer to a very interesting point in connexion with the 
history of the method. Born’s method was briefly announced 
in 1876 and was fully described by bim in 1883, and there 
seems no doubt that the credit of first publishing the method 
rightly belongs to him. But when in conversation recently 
with the librarian of the Royal Microscopical Society I was 
greatly interested to hear that something similar had been 
published quite independently in England about the same 
time. On Jan. 24th, 1879, Mr. E T. Newton read a paper 
before the members of the Quekett Microscopical Club 
explaining how he bad made a model of the brain of the 
cockroach. He evidently had experienced the great difficulty 
of visualising the form of objects cut into serial sections, for 
he remarks in his paper: “Anyone who in working out 
structures by means of sections has endeavoured to trace the 
various parts through a series of sections will understand 
how difficult it is to keep in mind the structures seen in 
each, so as to picture to himself the form of any part when 
entire. And still more difficult is it to convey to others the 
knowledge which one has gained by the examination of such 
a series.” In order to explain to the members of his club the 
details of the structure of the brain as obtained by an exa¬ 
mination of the sections, Mr. Newton marie plates of soft 
pinewood, each one-eighth of an inch in thickness, each plate 
corresponding to a section and cut out by a saw in the form 
of the section. When these were piled oDe on the other an 
entire view of the brain enlarged was obtained in the form 
of a wooden model. There seems no doubt that Mr. Newton 
thought out quite Independently the main principle under¬ 
lying the method of reconstruction by plates, though it was 
some three years later than Born’s first publication. 

[A demonstration was then given of the details of Born’s 
method of reconstruction by wax plates, illustrated by 
models and lantern slides. In brief, this may be described as 
follows. The sections of the embryo are drawn on a thin 
sheet of paper either by the aid of a camera lucida or a 
projection apparatus and special drawing board at a mngnifi- 
cvtion of 25, 50. or 100 times the size of the section, as 
desired. Each sheet of paper is then placed on a stone. 


such as is used in lithographic work, and melted wax is 
poured over it. When partly solidified it is well rolled, the 
thickness of the wax being determined by two brass strips, 
one on either side of the sheet and either one-half a milli¬ 
metre or one millimetre in thickness, according to a calcula¬ 
tion based on the thickness of the section and the 
magnification of the drawing. In this way wax plates are 
obtained from which the shape of each drawing can be 
readily cut by a sharp knife. These are all piled one on the 
other and when completed give a reproduction in wax of the 
form of the embryo magnified in accordance with the 
number arranged at the time of drawing.] 

The special features of Born’s method of wax plates are 
its comparative simplicity and its accuracy. It largely 
excludes the personal element in the making of the model 
and does not demand a great degree of technical skill or 
dexterity. Patience, thoroughness, trustworthiness, and 
enthusiasm, with dogged perseverance are the attributes 
necessary for him who will reconstruct in wax a complete 
model of a human or any other embryo in the early stages of 
development. As I said before, the training is an excellent 
one and the experience gained is invaluable for carrying on 
future work in whatever branch of medicine that work is to 
be done. I hope that the time is not far distant when some 
of our students who have the opportunity and the inclination 
will be prepared to take up work along these lines. They 
will not regret it. “ The harvest truly is plenteous, but the 
labourers are few.” 

Most of you will doubtless remember the following words 
of the Right Hon. Lord Avebury in his charming book “ The 
Pleasures of Life ” : “ There never was a time when thought 
was freer or when modest merit and patient industry were 
more sure of reward.” How very applicable these words 
are when applied to the study of embryology by means of 
modern methods. We must not, however, regard embryology 
“as a master-key that will open the gates of knowledge” 
and remove all the difficulties in our way without great 
efforts on our part. As A. M. Marshall remarked in one 
of his lectures: “It is rather to be viewed and treated as 
a delicate and complicated instrument, the proper handling 
of which requires the utmost nicety of balance and adjust¬ 
ment, and which, unless employed with the greatest skill 
and judgment, may yield false instead of true results. We 
are indeed only just beginning to understand the real 
power of our weapons and the right way of employing 
them, and in the future embryology, especially when 
studied in connexion with palaeontology, may be con¬ 
fidently relied on to afford a far clearer insight than we 
have yet obtained into the history of life on the earth.” 
Born’s method is obviously a most valuable aid in embryo- 
logical research and is almost universally used in the German 
universities. In England, up to the present, it has not been 
much in evidence and there is, I think, a great future for an 
embryological school in London. If our University could see 
its way to provide such an institution, properly equipped 
and endowed, there might be a better chance of contributing 
our fair share towards the elucidation of the multitudinous 
problems in embryology which are still waiting solution. A 
great deal has already been done in this country but there is 
an enormous amount still to be accomplished, and this can 
best be dealt with by providing special facilities for those 
who are anxious to take a share in the task. 

Much has been made in the past of the similarity in 
external form and internal structure which characterises the 
embryo of man and other animals in the early stages of 
development. That this is an embryological truth of the 
first magnitude no one will deny, and Haeckel, Darwin, and 
Huxley have drawn important deductions from this striking 
law. Von Baer himself having three unnamed embryos in 
his collection could not say in which group of vertebrates, 
reptiles, birds, or mammals, they were to be placed, and a 
still more striking illustration is afforded by the remarkable 
controversy which was kept up for many years over Krause’s 
famous embryo. “In 1875,” Marshall tells us, “Krause 
described an early human embryo which appeared to differ 
from all known human embryos in having a large vesicular 
allantois like that of a chick or a reptile instead of the 
allantoid stalk by which the human embryo is normally 
connected with the chorion. The peculiarity with regard to 
the allantois was so marked that doubts were at once raised 
as to the embryo being really a human one, and Professor 
His asserted roundly that Krause must have made a mistake 
and that his specimen was a chick embryo and not a human 
one at all. An ardent, almost furious, discussion arose and 

continued for many years ; indeed, it was only in 1892 that 
the points at issue were finally put at rest, and it was shown 
that while Krause was right in describing his embryo as a 
human one he was mistaken in regard to the supposed 
peculiarity in the allantois, the bladder-like vesicle which h& 
took for the allantois being merely a pathological dilation 
of the allantoic stalk.” 

There seems, however, very good reason for believing 
that when the early embryos of man, ape, dog, rabbit, 
and other animals are reconstructed and enlarged in the 
same way as the human embryo shown this afternoon and 
compared there will be little or no difficulty in distin¬ 
guishing one from the other. I anticipate that as other 
models are made by Born’s method certain characteristics 
will become evident in each series—characteristics difficult 
to recognise and appreciate before the enlargement is carried 
out. I wish I could obtain embryos of the gorilla, chimpanzee, 
and orang outang of approximately the same age as the 
human embryo, the model of which is on the table. If these 
could be reconstructed in wax enlarged, say, 100 times, I 
would not be surprised if certain differences became apparent, 
from a study of which it would be possible to realise that the 
human embryo as early as the third week of development/ 
possesses certain characteristics by which it can at once be 
separated from those to which it is, zoologically speaking, 
nearest akin. 

I trust, therefore, it is clear that the evolution of 
embryology as a science took place to a greater extent; 
in the nineteenth century than in the centuries before. 
It is, indeed, at the beginning of the twentieth century 
still a comparatively new kingdom with vast territories 
still waiting to be explored. There is no royal road 
to it, only the strait gate and narrow path. There are 
few excitements; only the daily round and common task. 
There are no rewards as the world would count them ; only 
the joy and gladness which come from a close communion 
with Nature and the chance of wresting from her some of her 
secrets. In “Sartor Kesartus” Carlyle has sounded the call 
afresh which men have heard all down the ages, “ Produce I 
Produce ! Were it but the pitifullest infinitesimal fraction 
of a Product, produce it in God’s name, ’tis the utmost thou 
hast in thee : out with it then.” The torch of science burns 
brighter than ever to-day, and who can foresee what it shall 
illumine ’ As the illustrious von Baer eloquently ex¬ 
pressed it: “Die Wissenschafb ist ewig in ihrem 
Quelle, unermesslich in ihrem Umfange, endlos in ihrer 
Aufgabe, unerreichbar in ihrem Ziele ’* (“As for science, its 
source is eternal, its comprehension is immeasureable, its 
task is endless, and its final goal is unattainable”). 

References .—I Bhould like to acknowledge my great indebtedness to 
the following writers whose works I have freely drawn upon for this 
lecture: (li Dr. Oscar Hertwig (“ Handbuch der Entwickelungs-lehre 
der Wirbeltiere Erato Lieferung”); (2) Karl Peter (“Die Methoden 
der Iteconslruktion”); (3) C. 8. Minot (“The History of the Micro¬ 
tome”); and (4) A. M Marshall (“Lectures and Addresses”). The 
sketch of HIb'b life is taken from the obituarv notice which I contri¬ 
buted to the British Medical Journal in May, 1904. 


By W. ARBUTHNOT LANE, M.B., M.S. Loxd., 
F.R.C.S. Eng., 


In The Lancet of Feb. 22nd, 1902, p. 498, my teaching on 
e’eft palate, together with the technique of my operative 
procedure, was explained, and I now propose to submit with 
as little repetition of my former communication as possible 
my present-day practice in regard to the more difficult cases 
of cleft palate. 

In early infancy it is possible to provide a well vascularised 
thick flap which is practically three times as broaij as can be 
obtained when the teeth have begun to encroach materially 
on the mucous membrane or to perforate it, since the muco- 
periosteum covering the under and the outer surface of the 
alveolus can be made to form the outer two-thirds of the 
flap. In Fig. 1 there is represented an infant with gags in 
position for operation, the tongue being drawn forwards by a 
silk thread passed through the tip. The ligure gives a 
good idea of the space gained for operating. 

The general principle underlying the various operations 


which I perform for cleft palate is to close In the interval 

I between the edges of the cleft by mnco-periostenm in the 
case of the hard palate and by mucous membrane and sub¬ 
mucous tissue in the case of the soft palate. In the latter 
every care is taken to avoid damage to the muscles and 
nerves, the interval between the segments of the palate 
being filled in by a soft elastic curtain made up of opposing 
layers of mucous membrane and submucous tissue. If hare¬ 
lip exists the cleft or clefts in it are closed at the same time 
as the cleft in the palate. This is done for three reasons. The 
first and most important is that the soft parts which are re¬ 
moved necessarily from the margins of the lip may be of the 
greatest service in completing the closure of the anterior part 
of the cleft. The second reason is that I find that postponing 
the hare-lip operation for a time reduces the chances of union. 
The third reason is that the sooner the pressure of the 
complete lip is brought to bear upon the segments of the 

aloog the length of the edge of the cleft. The reflected flap 
with its scanty supply of blood derived from small vessels 
in its attached margin is then placed beneath the elevated 
flap the blood-supply of which is ample and it iB fixed in 
position by a double row of sutures. In this manner two 
extensive raw surfaces well supplied with blood and un¬ 
influenced by any tension whatever are retained in accurate 
apposition. If, on the other hand, the cleft is too broad to 
admit of its safe and perfect closure in this manner, one flap, 
comprising all the mucous membrane, submucous tissue, and 
periosteum, on one side is raised except at the point of entry 
of the posterior palatine vessels, while the soft parts on the 
opposite side are raised in a flap from which the posterior 
palatine supply has been excluded and which turns on a 
base formed by the margin of the cleft. Here we have a 
mobile, well-vascularised flap which can be thrown as a 
bridge in any direction and can be superimposed on the flap 

Fig. 1. 

Shows gags in position for opera: ion, the tongue being drawn forward by a silk thread passed through the tip. 

t upper jaw as well as upon a displaced premaxilla, should it 
< exist, the more rapid is the approximation of the bones 
t forming the front of the cleft and the restoration of the pre¬ 
maxilla to its normal relationship. The muco-periosteum 
covering the premaxilla is also uselul in helping to close the 

Practically the flap formation employed to close in the 
<’ hard and soft palate resolves itself into two methods. If the 
It | soft parts overlying the edges of the cleft are thick and 
vascular a flap is cut from the mucous membrane, submucous 
ic tissue, and periosteum of one side, having its attachment or 
base along the free margin of the cleft. The palatine 
j'ascular supply is divided while the flap is being reflected 
1 1 inwards and it depends for its blood-supply on vessels 
i l entering its attached margin. The mucous membrane, sub¬ 
mucous tissue, and periosteum are raised from the opposing 
S margin of the cleft by an elevator, an incision being made 

of the opposite side, the closure being necessarily rendered 
complete by flaps from the edges of a hare-lip. Obviously 
the surgeon must be guided entirely by his instincts and 
experience as to the best mode of closing any particular 
cleft, and this description of methods must be of necessity 
of a general character. 

As time goes on the damage done to the temporary teeth 
by the separation of the superjacent mucous membrane 
becomes steadily greater. Still, this is a matter of no 
moment as compared with the importance of the early 
closure of the cleft, since the milk teeth are often un¬ 
satisfactory in cases of cleft palate apart from operative 
interference, while the permanent teeth escape damage from 
it if undertaken sufficiently early in life. 

I now purpose to describe in detail the measures by which 
the principles that l have laid down for the closure of clefts 
are applied. In Fig. 2 I have attempted to indicate 


diagrammatically the details of the first method which I have 
described. It is intended to represent the roof of the mouth 
of an infant, showing a broad cleft involving almost the 
entire palate. The position of the alveolus is indicated by 
the three crosses X x X. 1 represents the incision which 

Fig. 2. 

A broad cleft involving almost tho entire palate. The 
incisions indicated by dotted lines. 

extends forwards and outwards through the muco-periosteum 
from the anterior limit of the cleft and which passes over 
and beyond the alveolus to its outer surface; while 2 com¬ 
mences at its outer limit and runs back along the outer 
surface of the gums about the junction of the cheek and 
alveolus. An incision (3) is then made from its posterior 
extremity along the free margin of the palate to the uvula. 
The flap included between these incisions is raised from the 
subjacent structures. It happens not uncommonly in the 
type of cleft palate illustrated by Fig. 2 that the 
septum presents a free margin which extends almost, 
if not quite, to the level of the cleft. In these 
cases I make an incision (4) through the mucous membrane 
and periosteum or perichondrium along the middle line of 
the septum with two small transverse incisions (5) at either 
end and turn down laterally the narrow Saps so formed, 

Fig. 3. 

The flaps indicated in Fig. 2 shown in position. 

leaving the cartilage or bone bared and exposed. By 
placing the flap, which has been raised, in position, the line 
along which it will rest on the septal margin can be readily 
defined. With a sharp knife the surface of the reflected 
flap is denuded of its covering of mucous membrane along 
the area of impact. By a series of sutures perforating the 
superjacently impo»ed flap and the margin of the septum if 
it be not too hard, or the flaps of mnco-perio-tenm if the 
edge be bony, the reflected flap is pinned securely to the 
septum. 6 shows the incision along the free margin of the 
cleft continued as 7, obliquely outwards and backwards 
aloDg the upper surface of the soft palate. The incision 8 
extends from the posterior limit of 7 along the lower free 
margin of the soft palate to the tip of the uvula and the 
incision 10 forwards and outwards from the anterior limit 
of 6 on to the alveolus. This last incision facilitates the 

raising of the flap on this side and of the introduction 
beneath it of the reflected flap from the oppo-ite side. 
After the muco-periosteum external to the incision 6 has 
been raised from the bone, the soft palate is freed from the 
posterior margin of the hard palate and the mucous mem¬ 
brane on its upper surface turned outwards to the position 
of 9. 

in Fig. 3 the flaps are shown in position. The sutures 
along the line 1 represent those attaching the septum to the 
reflected flap. Those along the line 2 show the sutures which 
unite the free edge of the raised flap to the under surface of 
the reflected flap, those along the line 3 anchor the edge of 
the reflected flap, and those along the line 4 connect the flaps 
where they form the free margin of the new soft palate. 

In Fig. 4 is illustrated the method of fixation of the 
reflected flap A A A A beneath the elevated flap b b b. The left 
portion of the diagram shows the flap raised from the bone 
through an incision along the free margin of the cleft while 

FIG. 4. 

Mode of fixation of reflected flap beneath elevated flap. 

fixed to it by a double row of sutures is the reflected flap 
which has been separated from the roof through a marginal 
incision along the outer aspect of the gum. 

Another common type of cleft palate in which the same 
method is frequently applicable is that illustrated in Fig 5. 
The cleft in the hard palate is to one side of the mesial line 
where the septum is formed continuous with the margin of 
the cleft. The cleft in the soft palate is much broader owing 
to its inclination towards the side containing the septum. 
The alveoluB, which is cleft also, is represented by three 

Fig. 5. 

A type of complete cleft, the incisions being indicated by 
dotted lines. 

crosses—xxx. The reflected flap is obtained from the 
segment of roof, shown in the left portion of the diagram, by 
an incision extending from 7 to 5 to 6 to 8. The mucous 
membrane, submucous tis*ue, and periosteum are raised from 
the bone and apoDeurosis of the soft palate. On the other 
side an incision is made from 9 to 1 along the edge of the 
cleft t,o 2, along the upper aspect of the Boft palate to 3, and 
from 3 to 4. The triangular area of mucous membrane and 
submucous tissue included within the triangle of flap on the 
upper surface of the soft palate is reflected inwards to the 
free margiD of the cleft, while the muco-periosteum is raised 
from the bone by an elevator and scissors introduced through 
the incision 1 to 2. The reflected flap is then placed beneath 
the elevated flap, and is retained firmly in position by a 
double row of interrupted sutures. 

Fig. 6 shows the flaps sutured firmly in position. Along 
9 to 4 are indicated the deep sutures which pass through the 
margin of the reflected flap and perforate the superjacent 
elevated flap, while those along 1. 2, and 3 represent the 
superficial sutures uniting the edge of the elevated flap to 
the adjacent under surface of the reflected flap. Along 3 to 


4 the posterior free margins of the reflected Haps are shown 
joined by sutures. 

Should the cleft involve only the soft palate, as is shown in 

Fia. 6. 

Flaps indicated in Fig. 5 shown in position. 

Fig. 7, the same method can usually be applied. The uvula 
on the left side of the diagram is pulled forwards so that the 
upper surface of the palate is exposed, and an incision is 
made from 1 to 2 to 3 to 4, through the mucous membrane 
and submucous tissue, which are dissected off the subjacent 

Fig. 7. 

Broad cleft of soft palate, incisions being indicated bj’ 
dotted lines. 

parts inwards to the margin of the cleft. From the area of 
the soft palate corresponding to the right portion of the 
diagram a flap is raised from its under surface by an incision 
from 1 to 5 to 6 to 7 to 8, and is reflected inwards to the 
margin of the cleft. 

Fig. 8. 

Reflected flaps indicated in Fig. 7 shown in position. 

Fig. 8 shows the flaps sutured firmly in position, the 
darkened area representing the portion of the palate left 
uncovered by mucous membrane. The deep sutures uniting 

the edge of the flap obtained from the under surface of the 
palate on the right side to the raw upper surface of the 
palate on the left side are indicated between 6 and 7, while 
along 1 2, and 3 are shown the sutures connecting the edge 
of the flap reflected from the upper surface of the left side 
of the palate to the raw under surface of the palate on the 
right side. Between 7 and 3 are the sutures connecting the 
posterior free edges of the flaps. The terms right, left, 
refer to the diagram and not to the body. 1 would point out 
that within a fortnight or three weeks any raw surface left 
becomes so perfectly covered in by new tissue as almost to 
defy differentiation from the adjacent mucous membrane. 

The application of the combination of reflected and 
pivoting flap is well illustrated by Fig. 9. This^is intended 

Fig. 9. 

to represent a double cleft palate with the premaxllla (p m) 
lying well in front of the level of the alveolar arch and fixed 
to the under surface of the tip of the nose, I. being the 
small mesial segment of lip fixed to the anterior surface of 
the premaxilla. The reflected flap is obtained by an Incision 
extending from 1 along the outer aspect of the alveolus, 
through 2, and on to 3, when it bends inwards aloDg the free 
margin of the soft palate to the uvula 4. The pivoting flap 
is obtained by an incision from 5, along the outer aspect 
of the alveolus, through 6, along the margin of the 
cleft in the hard palate from 7 to 8, along the upper 
surface of the soft palate to 9 and then to 10. 

Fig. 10. 

The area of mucous membrane corresponding to the tri¬ 
angle 8, 9 and 10 is raised and reflected inwards. The area 
of muco periosteum included in 5, 6, 7, and 8 is raised from 
the subjacent bone except at the point of entry of the 


posterior palatine vessels and nerves, which form the pivot 
on which this flap rotates. The mucous membrane is stripped 
from the premaxilla and from the free edge of the septum in 
the manner indicated by the dotted lines showing incisions in 
the diagram. Large flaps are cut from the portions of lip 
forming the edges of the cleft and great care is taken that 
they have an extensive attachment at their bases. The 
mucous membrane covering the lateral and lower aspects 
of the piece of lip lying in front of the premaxilla is 
removed (L). 

The reflected flap is first put in position: the mucous mem¬ 
brane, where it comes into contact with the under surface of 
the septum, having been rendered raw, is secured to it by 
sutures. The pivoting flap is then moved inwards upon the 
reflected flap, to which it is united firmly by a double row of 
sutures. Finally, the soft palate is closed in a similar 
manner. This is represented in Fig. 10. 

After this the triangular areas of muco-periosteum which 
were reflected from the premaxilla are fixed in position (see 
Fig. 11) where these are indicated by y. The flaps from the 

Fig. 11. 

Additional Saps to those in Fig. 10 shown in position. 

lips shown as F F are arranged with their raw surfaces 
upwards. These are united to the raw surfaces of the flaps 
from the premaxilla and of the reflected flap, and are also 
sutured by their margins to one another and to the free edge 
of the pivoting flap (see Fig. 12). 

Fig. 12. 

Lastly, the ala of the nose is cut away from the cheek on 
either side and is displaced inwards where it is united by 
sutures to the septum, and is sewn to the cheek in its new 
position. This I have attempted to indicate in the same 
diagram. Having brought the edges of the lip into accurate 
apposition by means of separate sutures, two sutures of linen 
thread are passed in the manner indicated in Fig. 13. The 

Fig. 13. 

needle perforates the lip from behind and is made to 
re-enter the anterior aspect of the lip through the same 

hole, and after traversing the lip transversely it again 
emerges and enters through the same hole, the needle passing 
directly backwards through the lip. When this thread is 
made taut and tied the opposing raw surfaces of lip are 
held in accurate apposition, and no scar whatever results 
from the presence of these deep sutures, which can be readily 
removed when they have served their purpose. In Fig. 13 
only one cleft in the lip is represented. Occasionally 
in clefts involving the soft palate, with probably a pro¬ 
portion of the hard palate, the soft parts forming the 
anterior two-thirds of the margin of the cleft are as thin as 
paper. In such circumstances the splitting of the flaps can 
only be effected up to a considerable distance from the free 
margin, or some means other than splitting must be adopted. 
In splitting a thin flap there is a risk of a failure of nutrition 
of a part of it, so that a hols remains at the anterior limit of 
the cleft. An aperture in this situation is often very difficult 
to close. I have met this difficulty most effectually by deal¬ 
ing with the cleft in a manner which at first sight appears to 
be more complicated than it really is. The object is to 
employ a large flap the vitality of which is of a very high 
order and this is insured by its containing the descending 
palatine vessels and nerves of one side. 

Fig. 14 shows a cleft involving the 6oft and part of the 
hard palate. On the left half of the diagram an incision 
represented as a dotted line commences at 1 well outside and 
behind the aperture through which the descending palatine 
vessels emerge. From that point it is carried forwards along 
the alveolar margin across the middle line 2 and along the 
alveolar margin of the opposite side to 3. It then extends 
along the outer limit of the soft palate to 7 and along 

Fig. 14. 

its lower free margin to 6. An incision is carried outwards 
and slightly forwards from the anterior limit of the cleft 4 
to meet the first incision at 3, and another from 4 along the 
upper surface of the palate to 5, and from 5 along the free 
edge of the palate to 8. The four-sided flap of the soft parts 
forming the anterior surface of the palate included between 
the lines 4, 3, 7, and 6 is raised and reflected inwards to the 
free margin of the cleft. The large flap 4, 3, 2, 1, con¬ 
taining the vessels and nerves, is elevated from the hard 
palate and is separated from the margin of the cleft in the 
hard palate. The triangular area of mucous membrane 
included between 4, 5, and 8 is reflected inwards from the 
upper surface of the soft palate to the margin of the cleft so 
as to leave a raw area of considerable size. 

The free edge of the quadrilateral reflected flap of soft 
palate 4, 3, 7, 6 is pinned by deep, indicated as 1 to 2, 
sutures to this bare surface so that sufficient areas of the 
raw surfaces on either side are brought securely into accurate 
apposition (see Fig. IS). The large flap is then buckled up 
so that its lower margin comes into apposition with the free 
margin of soft palate on the same side. These edges are then 
retained in apposition by sutures which also perforate the 
surface of the subjacent reflected quadrilateral flap. This 
junction is represented along the line 3 to 4. The remaining 
free edge of the large flap is then sutured to the lower edge 
of the soft palate 2, 4, 5, 6 and to the outer limit of the 
quadrilateral incision 6 to 7. It happens occasionally that 


it i8 impossible to close the whole length of the cleft by one 
single operation. 

Fig. 15. 

Reflected and pivoting flaps in position. 

Fig. 16 illustrates such a condition. The cleft is a very 
wide one and it is found inadvisable to attempt to close it 
by the reflection of flaps in the manner already described. 
An incision is made along the entire outer aspect of the gum 
along the line indicated 1, 4, 4, 4, 4. Two are made along 

Fig. 16. 

the direction of 2 and two others along the free inner 
margins of the cleft aloDg dotted lines 3, 3. Flaps are also 
separated from the septal margin. 

The flap included between 1 and 2 on either side is turned 
back, great care being taken of its posterior attachment, 

Fig. 17. 

The reflected and pivoting flaps of Fig. 16 shown in position. 

which is usually very thin. The flaps comprised between 2, 
3, and 4 are raised from the bone from before backwards, 
care being taken to avoid any damage to the descending 
palatine vessels. These flaps are then displaced inwards as 
in Fig. 17, upon the subjacent flaps 3, 4, 5, 6, the margins 

of which are united by sutures to the superjacent pivoting 
flaps 1, 2, 7, 8. The apposing margins of the pivoting flaps 
are then sutured together and to the subjacent mesial flap 
and, if possible, to tbe septum also along the line 1, 2. 

At a later period the posterior portion of the cleft may be 
closed in various ways, the method varying with the breadth 
of the cleft and the extent of material at disposal. The 
first and more generally applicable method is by reflecting a 
flap inwards on one side, leaving it attached by its inner 
margin, the other flap being rendered raw on its posterior 
surface and its area extended, as in Figs. 7 and 8. Tbe 
second method is to reflect a flap Inwards as before, while 
tbe flap from the opposite side is raised from the subjacent 
parts by an incision extending along its inner, posterior, and 
outer margins, so that it pivots anteriorly and can be made 
to cover the flap reflected from the opposite side. Or both 
flaps may be made, as in Fig. 18, to pivot upon their anterior 
attachments ; their internal edges are sutured carefully 
together, the outer free margins being anchored wherever a 
suitable attachment can be found. The free inner margins 
of the cleft are also pinned down to the superjacent flaps by 

In Fig 18 the dotted outline 1, 2, 3, 4 represents the form 

Fig. 18. 

Mode of employment of pivoting flaps to close gap left in 
Fig. 17. 

of the flap cut from the under surface of the palate. This 
pivots upon its attachment 1, 4. 

In Fig. 19 these pivoting flaps are shown 'in apposition 
along the line 4, 5, where their edges are united to one 

Fig. 19. 

Pivoting flaps outlined in Pig. 18 shown in position. 

another. Their outer margins are united to the exposed 
surface of the soft palate along the line 1, 2. 

Cavendish square. W. 

The Sanitary Inspectors Examination Board. 

—An examination for certificates of qualification for appoint¬ 
ment of sanitary inspector or inspector of nuisances under 
Section 108 (2) (d) of the Public Health (London) Act, 1891, 
will be held at the Examination Hall, Victoria Embankment, 
London, on Tuesday, Jan. 14th, and the four following 
days. Particulars will be forwarded on application to the 
honorary secretary, the Sanitary Inspectors Examination 
Board, 1, Adelaide Buildings, London Bridge, London, E.C. 


[Jan. 4,1908. 


F.R.O.P. Lone., 


The results which I have obtained with the kinematograph 
as an aid in the teaching of nervous diseases, and which I 
have been able to demonstrate at the Middlesex Hospital and 
elsewhere, have met with such expressions of encouragement 
from my colleagnes and other members of the medical pro¬ 
fession as to lead me to think that it may be of some interest 
to publish a few notes on the nses and possibilities which 
this method of demonstration appears to offer. In connexion 
with the teaching of medicine diseases of the nervous 
system are especially well adapted for bioscopic illustration, 
since the abnormalities of movement can be all faithfully 

The illustrations accompanying this article are enlarged 
from isolated examples taken from a section of films and 
they depict the momentary attitudes of the patients as 
photographs were being taken of them at the rate of 16 a 
second. For the care and trouble taken in producing these 
films I have to thank Mr. Charles Urb in. From the appear¬ 
ance of these enlargements some idea may be gathered of 
the sharpness of definition which is obtained in the original 
films. These are all pictures of abnormal movements of 
pronounced character and will form the basis of the demon¬ 
stration which, at the invitation of the council, I hope to 
give before the Medical Section of the Royal Society of 
Medicine at the end of January. 

ill The first figure illustrated is that of a man with ataxy of 
the limbs who is depicted in this photograph as he is in the 
act of turning and the position of the left leg, in which the 
trouble is the more pronounced, gives some idea of the type 
of gait which can be so well seen in the moving pictures, as 
likewise can the incoordination of the arms, and the tendency 
to fall backwards, to which he is also subject. 

The next two figures are illustrations from a case of 
disseminated sclerosis. The ataxic-paraplegic walk and the 
attempts to preserve the balance by the movements of the 
arms are well shown ; in the second picture the patient has 
been photographed while in the act of drinking in order to 
bring out the “ volitional ” tremors. His efforts to raise the 
glass to his lips, accompanied as they are by tremors of 
increasing amplitude and spilling of the water, make up a 
picture which cannot fail to impress itself on all who see it. 
From this case films have also been taken to show nystagmus 
and the rapid oscillations of the eyes as they are turned to 
one side or the other can be clearly seen and, moreover, can 
be contrasted with an example of slow nystagmus which has 
been obtained from a case of Friedreich’s disease. 

In the fourth figure we have an example of a paraplegic 
gait resulting from a myelitis. 

The fifth picture is taken from a case of pseudo-hyper- 
trophic paralysis in which the characteristic waddling 
method of progression is shown, and here the instantaneous 
photograph has depicted the patient’s right leg in the posi¬ 
tion of “ high-stepping” gait which is so apt to be assumed 
by patients with such muscular weakness as makes it difficult 
for them to clear their feet from the ground. Bioscopic 
illustrations have also been obtained of the method by 
which this patient gets up from the ground by 1 ’ climbing up 
his legs.” 

The sixth figure is taken from a case of cerebral diplegia 
with athetosis. The continual squirming, involuntary move¬ 
ments which affect the head and face as well as the hand, are 
realistically shown and films have also been obtained of the 
patient walking. 

The seventh figure illustrates the posture of a case of para¬ 
lysis agitans, and by means of the bioscope the characteristic 
tremor of the hands can be seen. The typical “mask’’-like 
face can be easily identified by a series of pictures which 
show the rigidity of the countenance being maintained while 
the patient is talking, and this has been made atill clearer by 
comparison with the facial expression of another case in 
which tremor has arisen from a different cause. 

The last picture shows the act of testing the kDee-jerks. 

Enough has been said to give a general outline of some 
of the movements which have been already photographed 
for demonstration, but it is, of course, possible to record all 

the main diagnostic points of a case, as in one instance has 
been done. The absence of signs can also be recorded as 
well as their presence and the presence or absence of anaes¬ 
thesia can be demonstrated by asking the patieDt to raise his 
hand or to make other signs indicating his abilities to feel or 
not as the case may be. To begin with, one has natnrally 
chosen cases where the movements have been of an ex¬ 
aggerated nature, but the fact that nystagmus can be shown 
is a clear indication of what can be done with movements 
which are less pronounced. Indeed, given a suitable light, 
it is possible to take the finest movements and I hope 
shortly to be able to demonstrate this by showing the move¬ 
ments which occur during the electrical reactions of muscles. 

No doubt ideas will occur to readers in which a record of 
many medical cases other than those of nervous diseases will 
be useful, for the whole aspect of a case is often different 
according to whether it can be seen in lifelike movements 
or only in stationary illustrations. The practice of surgery 
would also seem to offer great facilities for demonstration by 
kinematograph, but hitherto, so far as I am aware, little 
or no serious work has been undertaken for purposes of 
teaching. It is true that a French surgeon has had bioscopic 
pictures taken of some of his operations, and extremely 
Interesting as these pictures are in depicting technique and 
in demonstrating the possibilities which are thns opened np 
they caDnot be regarded as being of serious use for sys¬ 
tematic instruction. For the purpose of instruction it is 
necessary that the great principles should be illustrated and 
for this purpose it will almost certainly be best to take 
photographs from the cadaver where the desirable positions 
and lights can all be arranged at leisure. Operations on the 
eye would probably afford excellent examples for teaching 
purposes, as also would the manipulations of dislocations 
and fractures. Needless to say it is neither necessary nor 
desirable that the identity of the operator should be brought 
into the pictures. Only his hands need be taken and, indeed, 
apart from obvious ethical reasons, to do otherwise would 
to a large extent decrease the value of the photograph by 
obtaining an extended field at the expense of a loss of 

Photographs of moving micro-organisms must be ranked 
among the most striking results that have hitherto been 
obtained with the kinematograph. The movements of the 
various bacilli—e.g., those of typhoid fever—can be shown 
on the screen and should be of value in the teaching of 
hygiene and bacteriology. The teaching of physiology 
should also benefit by this method, inasmuch as various 
physiological experiments which it is frequently impossible 
to repeat before a class could be demonstrated as often as 

For the general purposes of class teaching in medical and 
other forms of education there can be no doubt that the 
kinematograph will prove to be very useful and its manage¬ 
ment is but little more trouble than that of the ordinary 
lantern. Moreover, with the most modern types of machine 
it will be possible to stop at any one picture and thus to 
combine with the kinematograph all the advantages of an 
ordinary lantern without any danger of firing the films. 

It may be taken, however, that we are as yet only at the 
beginning, so to speak, of this method of observing pictures 
of moving life, and, indeed, I am given to understand that 
at the present time a small hand machine in which the 
movements will be obtained by a simple clockwork motor 
and for the illumination of which the reflected light of an 
ordinary electric lamp, candle, or daylight will be sufficient, 
is in course of construction. Such a contrivance will form 
an important addition to the equipment of the practitioner 
who is unable to keep in touch with the larger centres of 
education, for in addition to his reading he will be able to 
study many of his cases as they appear in life, and to the 
student there will be given another valuable method of 
revising and summarising his knowledge. 

Queen Anne-street, IV. 

Descriptions of Illustbations on Page 13. 

Fig. 1 .—Case of ataxy showing patient in the act of turning. 

Fig. 3 .—Case of disseminated Bclerosis showing an ataxic-paraplegic 

Fig. 3.— Intentional tremors in disseminated sclerosis. Note the 
spilling of the water as the patient attempts to raise the glass to bis 

Fig. 4 _a caso of paraplegia following myelitis. Note the manner 
in which t he left foot is being dragged along. 

Fig. 3 .—A case of pseudo-hypertrophic paralysis Bbowing the 
waddling and ** high steppage ” gait. 

Fig. ti —A case of cerebral diplegia with bilateral athetosis. 

Fig. 7 .—A case of paralysis agitanB in characteristic attitude. 

Fiff. 8 .—Photograph to show the knee-jerks being tested. 

The Lancet,] 




By W. CECIL B03ANQUET, M.A., M.D.Oxon., 
F.R.C.P Lond., 


The following cases of diabetes appear to possess some 
points of interest which may render them worthy of record. 
The first patient came under my care on the occasion of his 
first stay in hospital, after the most acute period of his 
attack was past, the credit for the successful treatment being 
due to Dr. F. W. Mott, whom I have to thank for permission 
to publish these notes. 

Case 1.—The patient, a boy, aged 14 years, was admitted 
to Charing Cross Hospital on May 16th, 1905. complaining 
of increased hunger and thirst, of loss of flesh, of the 
passage of large quantities of urine, and of pain in the 
abdomen. All these symptoms were of five weeks’ duration 
and had apparently arisen almost suddenly. For the last 
three weeks the lad had noticed that his sight was bad and 
he had stayed away from school in consequence. His past 
history had been uneventful, but he had suffered from 
alopecia areata for the past five years and at the time of 
admission exhibited extensive areas of baldness chiefly affect¬ 
ing the right side of the scalp. His mother and a cousin had 
died from diabetes, and both of these relatives had been 
affected with alopecia in the same region as the present 

On examination the patient was fonnd to be a somewhat 
emaciated youth, with a flushed face and somewhat dirty 
tongue. The lower border of the liver was palpable just 
below the coetal margin ; no knee-jerks or plantar reflexes 
could be obtained. His mental condition was dull and 
drowsy but he answered questions intelligibly when 
roused. During the first 24 hours—being on an ordinary 
diet—he passed 56 ounces of urine containing 9'1 
per cent, of sugar (nearly 153 grammes). No acetone 
or diacetic acid was detected by the ordinary tests. 
On the 17th he was ordered a strict anti-diabetic diet 
with the exception of a daily allowance of two pints of milk, 
He was also given 25 minims of solution of morphine three 
times a day. The quantity of Bugar in the urine increased 
instead of diminishing. On the 19th he passed 374 grammes 
of sugar; the drowsy condition had deepened and acetone 
and diacetic acid were now present in the nrine in consider¬ 
able amounts. On the 20th and 21st he was practically 
comatose but could just be roused to take nourishment; no 
symptoms of “air hunger” were noticeable. On each of the 
last-mentioned days he was given an enema of saline solution 
containing one drachm of bicarbonate of sodium and on the 
23rd the doBe of eolation of morphine was increased to 
40 minims thrice daily. The lad's mental condition gradually 
improved and the quantity of sugar passed decreased con¬ 
currently. Some slight recurrence of the drowsiness was 
observed between July 3rd and 6th, but it did not become 
deep. Acetone and diacetic acid were detected daily in the 
urine up to June 14th and a trace of one or other was found 
on a few subsequent occasions. On the whole, fairly steady 
improvement took place. On the 16th it was discovered that 
by a mistake on the part of the nursing staff the patient had 
been receiving a daily “portion” of milk pudding (rice, 
tapioca, sago). This was ordered to be discontinued. The sub¬ 
sequent history of the case while in hospital was uneventful. 
The reduction in diet was not immediately followed by any 
marked diminution in the amount of sugar excreted in the 
urine bat gradually the quantity of urine fell, the percentage 
of sugar remaining at first pretty constantly about 4 per 
cent. The dose of morphine taken was reduced on July 1st 
to 25 minims and on August 8th to 15 minims thrice daily. 
The boy left the hospital much improved on August 19th. 

The patient was readmitted on Jan. 9th, 1906. His weight 
was then 6 stones 4i pounds. For the first month of his 
stay in hospital, during which he was plaoed on a Btrict anti¬ 
diabetic diet with the exception of the same allowance of 
milk as before, he passed on an average 266 grammes of 
sugar per diem. On Feb. 23rd he was ordered one ounce 
daily of acid extract of duodenum (secretin) kindly supplied 
by Professor E. H Starling. The amount of sugar excreted 
appeared quite uninfluenced by the remedy ; the acetone and 
diacetic acid present in the urine Beemed to increase slightly 

but they were not quantitatively estimated. The secretin 
was discontinued on March 1st. On the 7th the patient was 
given a daily portion of tapioca padding ; again there seemed 
to be some increase in the amount of acetone bodies excreted 
in the nrine but the amount of sngar did not rise, the 
average at this period being approximately 200 grammes 
daily. Gradual diminution in the quantity of urine was 
recorded after this date. On April 11th the boy was allowed 
four ounces of potatoes daily but still no increase in sugar- 
excretion occurred. He left the hospital, improved in general 
condition, on April 18 h. Subsequently he attended at 
intervals in the out patient depart meat, remaining apparently 
in much the same state. At the beginning of November, 
however, be got rapidly worse and was readmitted on the 
27th of that month—bis first appearance at the hospital for 
some weeks. He was now very drowsy and was roured with 
difficulty. The urine contained 2 5 per cent, of sugar and 
much acetone and diacetic acid. His weight was 5 stones 
2i pounds. His temperature rose to 102 4° F. and he died 
comatose on the second day after admission. 

At the necropsy no apparent cause for the fever was dis¬ 
covered. The pancreas was extremely atrophic, weighing 
only one ounce. Microscopically it exhibited slight fiorosis 
and some fatty change ; the islands of Langerhans appeared 
normal. The kidneys were large, weighing seven ounces each, 
and on microscopical examination they Bhowed parenchy¬ 
matous nephritis. 

Case 2—The patient, a yonth aged 20 years, was admitted 
to hospital on Dec. 17th, 1905. His illness had begun 
gradually five years before with thirst as the prominent 
symptom. Three months before admission the thirst had 
increased and the patient became weak. His vision grew 
indistinct and his gnms became sore and swollen. 

On admission the patient appeared to be weak and listless. 
He had a small carbuncle on the right cheek, and Mr. 
E Treacher Collins found commencing cataract in both eyes. 
The urine contained a considerable quantity of sugar, reach¬ 
ing 340 grammes in the first 24 hours and 470 grammes on 
the second day. He suffered from what he called “ diarrhoea,” 
the frequent passage of large formed motions. On the 20th 
he was strictly dieted, with the exception of an allowance of 
two pints of milk. After this the average amount of sngar 
passed in 24 hours was about 160 grammes. From Jan. 9th 
to 12th, 1906, he was drowsy ; his skin was moist and the 
“ diarrhoea ” continued. On the 23rd he was put on secretin, 
two ounces of the acid extract of duodenum supplied by 
Professor Starling being given daily. This was continued 
till Feb. 11th. The amount of sngar passed dnring this 
period was on an average 170 grammes. Aostone bodies, 
which had appeared previously, increased in amount, and the 
diarrhoea became more troublesome. The motions contained 
some undigested muscle fibres and 12i per cent, of fat. On 
Feb. 7th he surreptitiously ate a currant bun and true 
diarrhoea with liquid stools supervened. The patient became 
obviously more ill and drowsy. On discon tinning the secretin 
gradual improvement occurred—subjective at first, but after¬ 
wards objectively apparent. From the 11th to March 2nd 
the average daily amount of sugar secreted was approximately 
124 grammes ; the acetone bodies varied in quantity from 
time to time. On March 8th he was again worse, being 
more drowsy and haviDg more diarrhoea. He was given 
strychnine, brandy, and doses of sodinm bicarbonate. 
During the 12ih and 13th he was put upon a milk 
diet alone. In spite of everything the diarrhoea continued 
to be troublesome and the patient appeared to be 
getting weaker. On April 4th a change of diet was tried, 
four ouncee of potato being added to the daily portion. The 
sugar in the urine rose somewhat, averaging during the first 
week 171 grammes daily. The patient seemed in spite of 
this to gain strength ; the diarrhoea was no worse. On the 
11th he was given in addition to the potato a portion of 
milk-pudding and again the sugar rose slightly, reaching 
180 grammes, but the general improvement continued. On 
the 23rd a final addition of four ounces of bread was made. 
The sugar rose no further but tended rather to fall in 
amount, the subsequent average being 136 grammes up to 
May 7th, the last estimation made. He was discharged to 
the convalescent home on May 30th still suffering from slight 
diarrhoea but stronger than he had been for some time. At 
the end of a week at the home the diarrhoea became so 
severe as to render it advisable for him to return to 

The patient was readmitted on June 9th, 1906. The 
diarrhoea was troublesome and there was Borne edema of the 


ankles. The pulse was weak and frequent and the patient 
seemed ill and exhausted. His weight was now 6 stones 
11 pounds. He was again dieted and was treated with 
enemata of starch and opium for the first lew days, 
receiving later a mixture containing salicylate of bismuth. 
The diarrhcea gradually lessened in severity but remained to 
some extent throughout his stay in hospital. At one period 
he developed a small carbuncle in the left external auditory 
meatus and the parotid lymphatic glands became swollen ; 
this condition subsided satisfactorily. The record of the 
daily excretion of sugar at this period is unfortunately so 
imperfect as to render it impossible to draw any valid 
inferences therefrom. The patient gradually gained 
weight, reaching 6 stones 5 pounds, and went home 
on August 22nd at bis own desire. He came up as 
an out-patient on Sept. 7th and again on the 14th. 
On the latter occasion he looked weak and ill but 
professed to be as usual and declined admission. In the 
following week, however, he was much worse and seemed 
scarcely able to walk. He complained of nothing but the 
diarrhcea and would not admit that he suffered from thirst, 
polyuria, cough, or any other trouble. He was readmitted 
rather against his inclination, it being obviously dangerous 
to allow him to leave the hospital. On admission he became 
much collapsed, the pulse being scarcely perceptible. The 
urine contained a large percentage of sugar but no acetone 
or diacetic acid. He rallied a little under the influence of 
stimulants. His temperature rose to 103 8° F. Signs of 
consolidation of the upper lobe of the right lung were dis¬ 
covered, incontinence of urine and farces ensued, and he died 
on the next day from exhaustion without any sign of coma. 

At the necropsy the upper lobe of the right lung was found 
to be covered with a layer of fibrinous exudation. The lung 
itself was the seat of caseous pneumonia. The duodenum 
and upper part of the jejunum were thickened throughout 
and the mucous membrane was covered with a layer of 
mucoid material. Microscopically the mucosa was infiltrated 
with leucocytes and the epithelium exhibited an undue 
number of goblet cells; the peritoneal coat was slightly 
thickened. There was pigmentation from chronic conges¬ 
tion in the region of the caacnm and here and there through¬ 
out the colon. The kidneys showed some cloudy swelling 
but were otherwise normal. The liver was somewhat fatty. 
The pancreas was much reduced in size, weighing only 
H ounces (37 grammes). The secreting substance was 
especially diminished in amount, there being a considerable 
quantity of fibrous tissue around the duct of Wir-ung which 
helped to make up the small weight actually recorded. 
There was no fibrosis of the gland, although the arteries 
were much degenerated (arterio-Bclerosis). The islands of 
Langerhans were visible in fair numbers and appeared 
normal in structure. 

Comment» —1. The hereditary incidence of diabetes is 
well illustrated in the cases recorded, no less than four 
members of one family being affected. The coincidence of 
alopecia areata in three of them is remarkable. 

2. In Case 1 the rapid onset of the disease is noteworthy, 
as is also the abdominal pain by which its appearance was 
accompanied. The occurrence of some aente affection of the 
pancreas is suggested. In the other brother the disease had 
lasted for five years and held begun more insidiously. No 
exciting cause was traceable in either instance. 

3. In Case 1 the recovery from so deep a condition of 
coma was remarkable. The lad subsequently died comatose 
and the kidneys showed acute inflammation. The associa¬ 
tion of coma in diabetes with renal defect is worthy of 
careful investigation, as the rapid accumulation of the 
poisons at work is most easily explained by the occurrence 
of some failure in the excretory apparatus. In a recent case 
of fatal coma occurring in Charirg Cross Hospital there was 
fonnd suppurative nephritis, and in my own experience it 
is usual to find signs of renal mischief in such cases. The 
relation of coma to acetomemia is illustrated in these cases, 
the second patient who died from pulmonary disease without 
coma not exhibiting these bodies in the urine at the end. 
It was noteworthy, however, that Case 1 on first admission 
was drowsy but exhibited no acetonuria. The dependence 
of acetonremia on lack of carbohydrate food was not 
apparent, the first boy passing into coma and out again 
while taking a daily portion of milk padding, and some 
increase in the amount of the acetone bodies excreted being 
noted on one occasion (March 7th) immediately after an 
increase in the allowance of starchy food. 

4. In Oase 1 the amount of sugar in the urine varied inde¬ 
pendently of the diet taken. It rose notably as a sequel '.o 

putting the boy on a stricter diet—he had been taking 
ordinary food previously to admission. The subsequent 
omission of the unauthorised milk pudding did not cause an 
immediate fall in the excretion of sugar, nor on a subsequent 
occasion did an addition to the allowance of carbohydrate 
increase it. In the second case the lad seemed to improve 
considerably when allowed an additional amount of carbo¬ 
hydrate, iD spite of the slight increase of sugar excreted in 
the urine. The phenomena observed in these two cases seem 
to me to be in favour of the explanation of the origin of 
sugar in diabetes which I set out in my Goulstonim lectures 
in 1905—viz., that some portion of the sugar arises from a 
breaking-down of the cells of the body, in addition to that 
which may be due to some defect in the process of absorp¬ 
tion of sugar from the alimentary canal or of its destruction 
in the body. If this be the case a parallel may be drawn 
between the formation of sugar and that of uric acid, part 
of each beiDg exogenous, part endogenous. 

5. The failure of secretin to act bent ficially in either of 
these patients was disappointing. Since, however, the 
action of secretin as recognised by its discoverers is to 
increase the Dow of pancreatic (digestive) juice, its employ¬ 
ment in diabetes can only be upheld on the principle that 
the formation of the internal secretion of the pancreas and 
that of the digestive fermi nts take place as a single chemical 
action, the living substance breaking down simultaneously 
into both these substances. Now if, as I previously sug¬ 
gested, the action of the pancreas lies in neutralising some 
poison formed elsewhere in the body—such neutralising 
action consisting perhaps in making use of the substance 
in question for its own metabolism—the absorption of 
secretin will not directly affect the relation of the gland to 
the formation of sngar. 

6. The anatomical condition of the pancreas in these two 
cases was striking ; in each there was marked atrophy of the 
organ without noteworthy alteration of structure, the 
fibrosis in the second case being comparatively slight. In 
each case there were plenty of normal-looking islands of 
Langerhans. It is therefore difficult here to associate 
diabetes with structural lesions of these islands. The cases 
tend to support the view of Hansemann that the typical con¬ 
dition of the pancreas in diabetes is atrophy, affecting the 
secreting cells as a whole. In each of these cases there was 
well-marked arterio-sclerosis, which is in my experience the 
most constant feature in the pancreas in cases of diabetes, 
having been present in every one of eight cases which 1 have 
examined in the last two years. The hyaline change met 
with in the islands in some instances appears to be mosb 
often of the nature of an arterio capillary fibrosis ; in other 
cases hyaline blood-clots and degenerate cells may present a 
homogeneous appearance. 

7. The condition of the small intestine in the second case 
is noteworthy. It was clearly associated with the diarrhcea 
which was so troublesome daring life How far the diminished 
assimilation of fat and of muscle-fibre was due to the 
intestinal disease and how far to the pancreatic defect cannot 
be determined. The fact that some fibrosis of the pancreas 
occurred in the first case and not in the patient who suffered 
from duodenal catarrh suggests that this lesion was de¬ 
pendent upon the arterial condition and was not inflamma¬ 

Harley-street, W. 


By ALAN B. SLATER, M.D. Edin., 


A GIRL, aged 13 years, came under my charge on June 20tb, 
1907, with the following history. Three years previously she 
was taken to an eye hospital for inflammation ot the eyes. 
She was treated there at the time but the medical officer at 
the hospital told the mother that the child was very ill and 
that Bhe cught to have a medical man to attend her at home. 
The child, however, improved at home and no medical 
practitioner was sent for. A week or two later, the exact 
time is not known, the mother noticed when washing the 
child’s clothes that her linen was stained and on examining 
the child herself she found two white patches, one on the 
inside of each labium, and also a thin discharge. This was 


treated by the mother by bathing with water. Shortly 
after this blisters began to develop round the vulva and 
spread on to the abdomen. The child was then taken to a 
general hospital and was admitted, the vesicles having spread 
so rapidly that she was practically covered by them about 
the body and neck, and there were a few on the face and 
head. She remained in the hospital about five months and 
during that time made little or no progress, the only change 
being that the abdomen cleared and the vesicles were con¬ 
fined to the parts round the vulva, the chest, the neck, and 
the head (including all the face). Since then she has been 
treated for syphilis, a section taken of one of the vesicles 
showing some appearance of syphilis. 

Mercury and iodides were given for about two years with¬ 
out much effect, but the child’s general condition improved 
and the vesicles still were confined to the vulva, the chest, 
the neck, and the head, the face being especially affected. 
Lotions of almost every kind were used without having any 
effect. Some idea of the amount of discharge from the 
whole surface of the skin, due to the vesicles rupturing, may 
be obtained from the fact that during the whole time since 
she left the hospital her mother has had to change all 
her clothes, always twice, and as many as four times a 
day, in addition to wrapping all the affected parts in linen 
or cotton. 

On June 20th the child’s appearance and condition were as 
follows. There were masses of vesicles round the left 
Bide of the mouth extending to the cheek, but not into the 
mouth; others on both eyebrows, the right being worse than 
the left. The external meatus of both ears was filled with 
thick semi-purulent discharge, the lobes of the ears and 
behind the ears being covered with discharging vesicles. 
Upon the head were large masses of vesicles and some dried 
scabs where former ones had been. The neck and shoulders 
had large quantities of vesicles on them extending down to 
the nipples on either side and as far as the middle of the 
scapulae on either side at the back. In the areas affected 
the space between the vesicles was dark red, but in other 
areas which had been affected and where the vesicles had 
disappeared the skin was only slightly erythematous or even 
normal, no scarring being left behind. The region of the 
vulva was erythematous and studded with vesicles, but this 
condition did not go back further than the vulva itself ; the 
whole affected area thereabouts extended to three or four 
inches down the inner part of the thighs and about 
four inches up the abdominal wall. All the areas 
were discharging freely, a thin clear fluid dripping from 
the chin at the rate of a drop per minute In many 
places the vesicles were arranged in crescentic form as 
though the discharge had run over the surface of the skin 
and infected it as it went along. The general condition of 
the child was good ; she was well nourished and felt quite 
well in herself and also ate well. There was no sign of any 
constitutional disturbance, the spleen was not enlarged, the 
heart was normal, and the urine was free from albumin. 
From the following bacteriological investigation I decided to 
treat her by means of diphtheria antitoxin. 

Bacteriological report by Dr. J. G. Hare. —On June 30th 
I made a bacteriological examination of the serous fluid 
which was dripping from the face. Smears were made 
from the fluid and stained with methylene blue and 
by Gram’s method. In these were observed organisms 
resembling the diphtheria bacillus. I inoculated an agar 
tube and also a blood serum tube with the fluid and 
incubated them at 37° C. A growth appeared on the 
media 18 hours later. These were then plated and the 
staphylococcus aureus and albus were isolated, together with 
a bacillus which formed small cream-coloured colonies on 
agar. On smears being made from these colonies and stained 
with Ldflier’s methylene blue and examined a bacillus was 
observed closely resembling the bacillus of diphtheria. The 
organism also reacted to Neisser's stain. (In inoculating the 
tubes the needle was never allowed to touch the skin, the 
fluid being merely allowed to drip on to the needle.) The 
organism waa obtained in pure culture on blood serum 
and when stained and examined showed the characteristic 
involution (club-shaped) forms. Subcultures were then 
made on gelatin, on potato, in milk, and in broth. On 
gelatin the growth was slow and without liquefaction. In 
broth there was a whitish granular deposit at the bottom of 
the tube, the broth otherwise remaining clear. On potato 
a faint, almost invisible, growth was seen. Milk was not 
coagulated. Gas was not generated in any of the media. 
The indol reaction was obtained by the addition of a nitrite. 

Through the courtesy of Professor R. T. Hewlett animal 
inoculations were carried out at King’s College. A 300 
gramme guinea-pig was inoculated per peritoneum with two 
cubic centimetres of serum-suspension of this culture and 
at the same time another guinea-pig was inoculated with the 
same quantity of culture -+-1*5 cubic centimetres of diph¬ 
theria antitoxin. The first guinea-pig died in ten days ; the 
second developed no symptoms. The post-mortem appear¬ 
ance of the first guinea-pig showed extensive oedema of the 
peritoneum, haemorrhages, and enlargement of the spleen. 
Cultivations were obtained from the heart and peritoneal 
fluid and showed the Klebs-Loffler bacillus in pure culture. 

Antitoxin treatment .—This was begun on July 2nd. 2000 
units of Burroughs and Wellcome’s ordinary anti- 
diphtheritic serum were injected into the subcutaneous 
tissue of the abdomen at 3 p.m. At 10 P.M. there was 
some oedema at the seat of injection together with an 
erythematous rash all over the body and limbs and also 
discomfort from thirst. There was vomiting at intervals 
of an hour until 8 am. when it stopped and the child 
had a good sleep. By 1 p.m. on the 3rd the rash had dis¬ 
appeared and the patient was quite comfortable. By this 
time there was a marked change in the appearance of 
the vesicles, which had not only ceased to discharge but 
were, in many places quite dry and beginning to form a 
crust, the change being remarkable. The temperature 
remained at 99 8°F. On the 4th constitutional symptoms 
were still absent and at 1 p.m. 1000 units were injected. At 
6 p.m. no rash or other result of antitoxin was present but 
two of the areas became active again and discharged during 
the evening. The temperature was 99 8°. On the 5th 
2000 units were injected. No constitutional symptoms were 
observed during the day. The affected areas were reduced 

Fig. 1. 

Before antitoxin treatment. 

to three patches, the largest being one inch across. The 
discharge from others and from the ears had quite stopped 
and in many places the crusts had already come off, 
leaving healed skin. The diet was exclusively milk. 
The temperature was 99 6°. On the 6th no sym¬ 
ptoms were noticed until the evening after an egg 
and bread-and-butter had been eaten, when a slight 
erythematous rash appeared on the legs and abdomen. 
The patient was well in herself and hungry. The tem¬ 
perature was 99 6°. The vesicles were about the same. 
On the 7th there was a fine papular rash over the abdomen 
and thighs but no other symptoms. The vesicles were still 
discharging a little but no more had appeared and large 
areas on the shoulders and neck and head were quite free, 
only erythematous skin remaining. The vesicles were con¬ 
fined now to an area one inch across on the right side of the 
mouth, one similar on the left eyebrow, and two smaller ones 
on the front of the scalp. The vulva was quite free from 
vehicles but was utill erythematous. The temperature was 
99 4°. On the 8th the rash had all disappeared and the 
child was quite well in herself. The bullae were painted with a 


mixture of carbolic acid and glycerine. The temperature was 
99'4°. On the 9th the vesicles were discharging more and an 
affected area behind the right ear measuring three quarters 
of an inch across had appeared. 2000 units were injected. 
The temperature was 99 '2°. On the 10th there was no con¬ 
stitutional disturbance from the last injection. With the 
exception of that behind the ear all the others were drier 
and smaller in extent. The neck, the shoulders, and all the 
back of the head were free from even crusts. The vulva was 
free from vesicles also. The affected areas were painted 
with carbolic acid 1 to absolute alcohol 20 and afterwards 
dusted with boric acid powder. The temperature was 99°. 
On the 11th 2000 units were injected. All the vesicles were 
much drier, including the ear. The temperature was normal 
and the painting was continued. On the 12th no constitu¬ 
tional symptoms were observed. The vesicles were reduced to 
areas of a quarter of an inch behind the ear, one over the 
left eyebrow, and one of half an inch on the right Bide of the 
month. Painting was continued. The condition on the 13th 
was the same as on the previous day. On the 14th one vesicle 
reappeared on the front of the scalp and one on the left 
cheek : others were the same in extent but were discharging 
a little more. Other areas had kept entirely free and in 
many places the skin was normal; there was no scarring. 
The temperature was normal. On the 15th 2000 units were 

Fig. 2. 

After 7000 units had baen injected. Showing erythema left behind. 

injected. Withholding the antitoxin evidently allowed the 
disease to become active again, as single vesicles appeared in 
two new places on the face and the other ones were dis¬ 
charging more. On the 16th the discharge was less again, 
the single vesicles were dried up, and other areas 
were much drier; only three areas were discharging. 
On the 17th 2000 units were injected. There were no con¬ 
stitutional symptoms and every area was drier. The 
temperature was normal and painting was continued. On 
the 18th the patient was quite well generally. The affected 
areas were still smaller and there was very little discharge. 
The temperature was normal. On the 19th 2000 units were 
injected into the thigh. All the areas were frequently 
bathed with 1 in 20 carbolic lotion, then painted with 1 in 20 
carbolic in absolute alcohol, and dusted with boric powder. 
A culture was taken from the only discharging spot. On the 
20th the injection had caused the thigh to swell to almost 
twice the size and there had been great pain all night. The 
glands in the groin did not enlarge. The temperature ro=e 
to 101°. All discharge had completely stopped and a few 
crusts only remained. The tube inoculated on the previous 
day showed no growth of any kind after 24 hours’ incuba¬ 
tion. On the 21st the swelling of the thigh had disappeared. 
There was slight swelling over the seat of the injection. 
The condition had greatly improved and the temperature was 
normal. On the 22nd the improvement was maintained. 

Remark !.—There seems to be no doubt that the most 
important factor in this case was the Klebs-LofHer bacillus. 

The disease apparently commenced as an acute attack of 
diphtheria, the primary seat of infection being the eyes. 
From this focus the vulva became infected and then the 
bacteria in some way found their way into the superficial 
lymphatic circulation, producing a condition resembling 
herpes, probably as the result of peripheral neuritis set up 
by the bacilli themselves. This theory is based on the fact 
that during the whole of the duration of the disease, since 
the primary acute symptoms, the lesions have been confined 
to the superficial layers of the skin (proved by the fact that 
no scarring was left). Whether the staphylococci played 
any important part is difficult to say, but they probably had 
only a mild influence, if any at all, as the use of various 
lotions, such as 1 in 40 carbolic lotion, and perchloride of 
mercury 1 in 1500 had no effect on the lesions, whereas the 
effect of the antitoxin was remarkable. 

Bryanston-street, W. 


By C. H. TURNER, M.R.C.S. Eng., L.R.C.P. Lond., 


The patient, aged 23 years, was admitted to the Station 
Hospital, Rawal Pindi, on Jan. 4th, 1907. As history it was 
stated that on the morning of the 3rd, on getting up, he was 
seized with violent pain in the abdomen, chiefly the lower 
part, and vomited. He was admitted to the Cavalry Hospital 
and treated by enemata and fomentations to the abdomen ; 
these were effectual in opening the bowels, which had been 
constipated, and in relieving the pain considerably. He was 
transferred on the following morning to the Station Hospital. 

On admission the patient’s general appearance was good, 
both as regards colour and facial expression ; his tongue was 
furred but moist at the edges. The temperature was normal 
and the pulse was 100. He gave an intelligent account of 
the onset of his illness and complained at the present time of 
pain in the iliac fossa on the right side, radiating towards 
the umbilicus. He had vomited once during the night and 
had not had the bowels open or passed flatus since having 
the enemata the night before. On examining the abdomen 
there was seen to be Blight distension, and movement on 
respiration was impaired. There was slight general tender¬ 
ness over the abdomen, but more marked in the right lower 
quadrant; resistance here, too, was marked. No tumour 
could be made out. The percussion note was hyper-resonant 
over all the abdomen, with the exception of the right flank 
where the note was duil. A diagnosis of acute appendicitis 
with fairly extensive localised peritonitis was made and it 
was decided to operate if the pulse-rate had not dropped by 
the morning. The patient passed a restless night and the 
temperature, which had been normal on admission, was 
101° F. and the pulse was 112 ; he had vomited slightly twice 
during the night; the physical signs were the same, the 
pain if anything being more severe. 

Operation .—Chloroform being administered, the abdomen 
was prepared, as no previous satisfactory preparation had 
been possible owing to the tenderness. An incision four inches 
long was made over McBurney’s point, but a little farther 
out, the muscles being split in the direction of their fibres. 
On opening the peritoneum about six ounces of turbid peri¬ 
toneal fluid escaped, and distended and somewhat congested 
coils of 6mall intestine presented. The csecum could not be 
felt in the iliac fossa nor could any large intestine be pulled 
out. The incision was extended a couple of inches and the 
whole hand was introduced. A portion of the large intestine 
could then be felt quite collapsed and lying high up. This 
was pulled down easily and traced first in one direction 
where it was found to be continuous with the transverse 
colon; traced in the other direction it was found to take a 
turn upwards and forwards towards the umbilicus, and here 
a slight adhesion gave way and the caecum was brought out 
of the wound and examined; it was also collapsed and the 
appendix was found to be healthy. The ileum was then fol¬ 
lowed up and the first foot was collapsed and found to be 
firmly adherent at this point to the anterior abdominal wall, 
just at the level of, and to the right of, the umbilicus. The 
first incision was covered up with sterilised gauze and a 
second incision three inches long was made through the 
fibres of the right rectus muscle. On incising the posterior 
layer of the sheath of the rectus what was apparently an 


[Jan. 4, 19C8. 

abscess cavity containing four ounces of very off- nsive pus 
was opened. This was swabbed up and washed out with 1 in 
40 carbolic lotion and then explored with the finger; the 
walls were quite smooth and felt as though formed by 
mucous membrane. The peritoneal cavity was opened next 
and carefully packed off. The abscess cavity described 
above was then found to be the inner surface of the fundus 
of a dilated and gangrenous Meckel’s diverticulum, which 
was adherent to the anterior abdominal wall. It was then 
carefully separated and the coil of bowel from which it arose 
was drawn out ot the wound. The diverticulum arose from 
the ileum, about 12 inches from the ileo-cjccal valve ; its 
proximal portion was stenosed and its distal portion or fundus 
was gangrenous and dilated (as far as could be judged, 
for it had contained four ounces of pus) to the size of a 
Tangerine orange. The pathological condition was on a par 
with the “appendicitis with stenosis, empyema " classified 
by Mr. C. B Lockwood. The diverticulum was removed in 
the same way aB an appendix and the stump was tucked in, 
the wall of the intestine being brought together over it with 
Lembert's sutures. The displacement of the caecum was due 
to the mesentery of the ileum being adherent to the meso 
caecum and meso colon, and to slight adhesion of the 
omentum to the outer and posterior wall of the caecum. 
These were separated and all bleediDg points secured. A 
drainage-tube was placed in the whole length of the wound 
in the middle line and brought out at its lower extremity, 
and the abdominal walls were brought together over it with 
one layer of sutures, a separate layer for the peritoneum not 
being practicable owing to its friability. The wound in the 
iliac region was closed in separate layers. 

The after history of the case was as follows. The patient 
did not suffer from shock, though the operation lasted about 
one and a quarter hours. His condition gave rise to some 
anxiety for the first 26 hours, owing to the difficulty of over¬ 
coming the paralytic distension of the bowel, but this was 
effected by calomel and enemata, and the second day after 
the operation the bowels opened naturally and the hiccough, 
which had been rather persistent, stopped and the pulse-rate 
dropped from 120 to 98 Convalescence was uninterrupted 
and the wound in the iliac region healed by first intention. 
There was a fair amount of discharge from the tube in the 
other wound, but at the end of a week this had stopped and 
the wound soundly healed in 14 days. 

Remark *.—Cases of Meckel’s diverticulum are sufficiently 
uncommon to warrant their publication, and the above case 
is one of unusual interest from a pathological point of view. 
Cases in which the diverticulum has caused acute obstruc¬ 
tion by strangulating tbe bowel have been frequently re¬ 
ported, but I have not the literature at my disposal to look 
up the subject. I should be glad to hear if any cases of a 
similar nature have come under the notice of any readers of 
The Lancf.t. 

Kavval Pindi, Punjab, India. 






I have made a statistical analysis of the hospital records for 
156 cases of delirium tremens treated at the Philadelphia Hos¬ 
pital (Blockley) between Jan. 1st. 1904, and March 1st, 1907. 
In compiling statistics so as to display them in the form of 
tables it was found that the records of 16 of these cases were 
incomplete, therefore these have been omitted, and the 
tables include but 140 of the 156 cases treated. A number 
of cases that have occurred in my private practice could 
have been added, but it was deemed advisable to include 
only cases tbat bad received hospital treatment in order that 
one might obtain statistics that would be of definite value. 
An analysis of the 140 case records showed age to be not only 
a predisposing factor to delirium tremens but also to exercise 
a decided influence upon the gravity of this condition. The 
number of cases observed at tbe different decades, the 
number of deaths, and percentage of mortality are set forth 
in Table I. __ 

1 Published through the courtesy of Dr. Joseph Neff, Director of 
Public Health and Charities, Philadelphia. 

Table I. 


Total number 
of cases. 

Total number 
of deaths. 

Pecentage of 

20 to 30 years... 



33 3 

30 ,, 40 . 




40 .. 50 . 




50 „ 60 . 




60 „ 74 . 




Delirium tremens is most common between tbe ages of 30 
and 50, yet the death-rate remains almost the same during 
the second, third, and fourth decades. The prognosis is 
decidedly unfavourable in those suffering from this condi¬ 
tion after the age of 50 years, ami while the above statistics 
show a mortality of between 42 and 50 per cent, for such 
patients I am confident tbat a much higher death-rate is seen 
in private practice. Many of the cases included in Table I. 
had had a number of admissions to the delirium tremena 
wards of the hospital during the past 20 years. The greatest 
number of admissions for any one patient was 42. while 
many of the patients had had from six to 15 admissions, 
from each of which attacks they recovered and had been 
discharged from the institution as comparatively cured. 
These facts, though not included in any of my tables, are 
contradictory to the rather popular belief that those suffer¬ 
ing from delirium tremens usually end in death during the 
second or third attack. i 

Further analysis with reference to season as a predisposing 
factor and its influence upon the gravity of the condition is 
revealed by Table II. :— 

Table II. 


Number of 

Number of 

Percentage of 

January . 




February . 




March . 







10 0 

May . 








July . 




August . 



46 7 




40 0 

October . 



42 8 








72 7 

It will be seen by Table II. tbat tbe largest number of cases 
developed during the month of August when in this climate 
tbe heat is extreme. It is further of special interest to note 
that August gives a death-rate of 46 7 per cent., while the 
average death-rate is but 37 • 1 per cent. Extreme cold is 
not without influence upon the mortality-rate, since 
December and January gave the correspondingly high 
death-rate of 72'7 and 50 per cent respectively. During 
the spring months (May, April) delirium tremeDs is fairly 
common but the proportionate number of deaths is low, 
7-1 and 10 per cent. 

The following table (Table III ) is designed to present the 
various pre-existing and complicating conditions found to 

Table III. 

Pre-exlBting or complicating 

of cases. 





Cases with pre-existing cardiac ( 
disease.. . f 



84 6 

Cases developing cardiac com plica ( 
tionB .i 




Cases with pre existing kidney t. 
disease. i 



100 * 

Cases developing renal complies- ( 
tions .> 




Cases with pre-existing lung disease 




Cases developing pulmonary com- )_ 
plications ... .. S 




The Lancet,] 


[Jan 4 1908 1 9 

influence materially the mortality in 140 cases of delirium 
tremens studied, and of which 62 were fatal. 

Twenty-two of the cases displayed more than one pre¬ 
existing or complicating condition of which ten displayed 
kidney and lung involvement; seven heart and lung ; two 
kidney and heart; and three heart and stomach. Thirty - 
eight of the 140 cases were uncomplicated and all of these 
were followed by recovery. Most striking in connexion with 
Table III. ie that all of the 15 cases showing renal complica¬ 
tions terminated fatally. Again, great importance is to be 
attached to the prognostic significance of pre existing cardiac 
disease which gave a mortality-rate of 84 6 per cent.; and 
acute cardiac complications are of but little less importance 
as regards the seriousness of the condiLion in question. Those 
cases developing acute pulmouary conditions (bronchitis and 
broncho-pneumonia) gave a death-rate of but 66 per cent. 


dismissed in April, 1906, all the wounds had healed. About 
this time the patient noted a swelling at the lower end of 
the sternum but did not consult a medical man about it. 
On Maj 4th, as she was fixing hef handkerchief round her 
neck, she suddenly discovered another swelling near the 
upper end of the sternum and went to the out-patient 
department of the Salford Royal Hospital. I saw her in the 
out-patient room and admitted her into the hospital under 
the care of Dr. A. M. Edge. 

On admission she had two distinct and separate swellings 
in the region of the sternum, one at the lower end in the 
middle line and ODe at the upper end slightly to the right of 
the middle line. The lower swelling was about 3 inches long 
by 2 inches wide, tympanitic, soft, and moveable to a certain 
extent under the skin. There was no impulse on coughing, 
no breath sounds over it, and it was unaffected by taxis or 
pressure—evidently a collection of air in the cellular tissue. 
This gradually disappeared in a month’s time. The upper 

(SMral gales: 



By Thomas E. Cout.son', M.B., Ch B. Edin., 


Owing to the rarity of the condition the following case 
seems worthy of record. 

In November, 1905 a female, aged 56 years, was admitted 
into the Halford Union Infirmary suffering from a septic 

Fig. 1. 

Hernia before reduction. 

wound of the wrist and resulting cellulitis of the right 
axillary region with abscess formation. This was incised 
very thoroughly in three or four places and when she was 

Fig. 2. 

After reduction of hernia. 

BwelliDg gradually increased in size and presented all the 
signs of pneumocele. 

The notes at this time were as follows. On inspection it 
is situated over the upper end of the sternum, 5 inches in 
length and 3 inches in width. The outline is well defined 
and smooth and tapering to a blunt point over the first right 
intercostal space. It moves slightly with respiration rela¬ 
tively to the chest wall. On palpation it is fonnd to be soft 
and fluctuating. The skin moves over it and it can be 
moved a limited amount both up and down and side to side. 
Vocal fremitus is much increased over it and it has 
a most marked impulse on coughing which is easily visible 
as well as palpable. It does not pulsate. On percussion it 
is tympanitic to a marked degree. On auscultation there is 
bronchial breathing over it, low pitched, and interrupted. 
Vocal resonance is increased with whispering pectoriloquy 
There are no adventitious sounds. When the patient speaks 
the swelling bulges out and becomes quite tense. There is 
no pain. The temperature is normal and the pulse is normal. 

20 Thb Lancet,] 


[Jan. 4, 1908, 

On manipulation the swelling can be entirely reduced within 
the chest by gently pressing upon the fundus and fixing the 
blunt neck at the first intercostal space. The swelling 
vanishes with a squeaking sound quite audible both to the 
patient and to the operator. The sitting posture and a few 
coughs bring the hernia again into prominence. 

The photographs here reproduced were kindly taken for 
me by Dr. \V. B. Anderton. The one shows the hernia before 
and the other after reduction. 

My best thanks are due to Dr. Edge for kindly allowing me 
to record the case. 



By J. S, Manson, M.B., Ch.B. Edin., 


A mali: child, aged five months, was admitted to the 
Oldham Infirmary on Oct. 26tb, 1906, with a history of 
having swallowed a safety pin one hour previous to admis¬ 
sion. A skiagram was taken and the pin was seen to lie 
about the middle of the cesophaguB, open with the point 
upwards. It seemed a hopeless task to try to get the pin up 
by means of a probang, so it was resolved to push the pin 
down into the stomach and hope for the best. An 
ordinary stomach tube of small size was pushed down 
the oesophagus, and after withdrawing another skia¬ 
gram was taken showing the pin lying in the stomach. 
The child was kept in bed and watched carefully. 
Milk diet was given and four days after admission 

a dose of castor-oil. On the afternoon of Nov. 2nd the pin 
was found sticking half-way out at the anus. The pin took 
:ix and a quarter days to accomplish the journey from the 
mouth to the anus and only once or twice did the child seem 
at all fretful. 

The case ,-eems worthy of not) in showing the power of 
the alimentary canal in dea inr with a loieign hotly of a 
somewhat foimidable nature. I append a skisgram of the 
pin in the oesophagus. 


By Vaughan Pkni>rei>, M.D. Durh, F.R.C.S. Encj. 

A curious condition that justly has been called “mirrcr- 
writiDg ” has recently come under my observation. A bright, 
intelligent little lad, aged six rears, has been learning to 
write for the past six months. His governess reports favour¬ 
ably of his application and progress, and no abnormality 
save the one here reported has been noted. From a copy 
the boy writes correctly but if left to himself to exercise his 

new-found accomplishment, of which he is very proud, he 
starts at the right hand side of the paper and writes back¬ 
wards, so that to decipher the writing the paper has to be 
held up to a mirror. One day his mother suggested that he 
should write a letter to his grandmother. He began the 
letter as shown in Fig 1 (the G is correctly formed 
as he copied from a letter in his mother’s hand¬ 
writing). He selects the “ mirror-writing ” when asked 

Fig. 1. 

which is correct. He reads with equal facility both the 
normal and the abnormal types. For example, his mother 
indited in “ mirror-writing ” the invitation contained in the 
three first lines of Fig. 2, to which he instantly wrote, 
cnrrente calamo, the reply contained in the remaining lines 
of the same illustration. The most extraordinary confusion 
arises when he attempts “sums,” as shown in Fig. 3. A 
drawing that he made of a Great Northern locomotive 
engine illustrates the defect in a very marked way. The 

FIG. 2. 

engine is shown travelling to the left and is very well drawn 
for so youthful an artist; the letters G.N.R. on the tender 
are in “ mirror-writing.” In writing from dictation, unless 
he is corrected and carefully watched, he reverses his 

Are the pictures of letters in the boy's memory-centre 
incorrectly stored and therefore incorrectly reproduced ? 
Does the receptive apparatus in the occipital lobes play this 
strange prank with the naturally inverted picture of letters 

Fig. 3. 

svos: si is Cl 

received on the boy’s retinae ? It must be noted that the 
letters are not inverted as would be the case if the brain 
merely failed to right the retinal images. I incline to the 
former hypothesis as it is only in the reproduction of written 
words that he fails and is quite secure in making a copy. 


The Lancet,] 


[Jan. 4, 1908. 21 

Stelriral Badtins. 


Action of Digitalis in Cardiac Dictate.—Reminiscences of an 
Apprentice 50 Years Ago. 

* A* meeting of this section was held at the Apothecaries’ 
Hall on Dec. 17th, 1907, Dr. F. H. Burton-Brown, the 
President of the section, being in the chair. 

Dr. James Mackenzie read a paper on the Action of 
Digitalis in Cardiac Disease. The results of animal experi¬ 
ments, he said, must be accepted with caution. In man 
the effect of digitalis was entirely dependent upon the 
particular leBion. If dilatation was absent, and if the 
tonicity of the heart was preserved, then no good resulted 
from the use of digitalis. If the heart was of normal 
size dropsy was not of cardiac origin. The irregular 
pulse of mitral disease was to be explained by the observa¬ 
tion that in these cases of mitral disease there was a ven¬ 
tricular inception of the heart beat. To illustrate these 
and other points Dr. Mackenzie showed a series of tracings 
He also showed a heart dissected to display with great 
clearness the auriculo-ventricular bundle.—In the discus¬ 
sion which followed Professor A. R. Cushny spoke of 
the immense value of the accurate scientific observations 
made at the bedside by Dr. Mackenzie. The difficulty 
of the subject was very great. Even in experimental work 
with the same dose of digitalis, given in the same way 
to the same animal, the results varied widely from time to 
time.—Dr. H. 0. Cameron asked whether l)r. Mackenzie's 
work had led him to form any opinion as to the rapidity with 
which digitalis acted.—Dr. Mackenzie, in reply, stated that 
as a rule the characteristic changes in tracings due to 
digitalis were not apparent for about 10 days. 

Dr. W. Soper then read an interesting paper on Remini¬ 
scences of an Apprentice 60 Years Ago. He described the 
forms of treatment which prevailed 50 years ago and com¬ 
pared them with more modern methods. The system of 
apprenticeship, he maintained, had many advantages. 


Recent Work on the Cause , Prevention , and Treatment of 
Mediterranean, or Undulant, Fever. 

A meeting of this society was held on Dec. 12th, 1907, 
Sir Herbert M. Ellis, the President, being in the chair. 

Fleet-Surgeon P. W. Bassijtt-Smith, R N , in a paper on 
the above subject gave an interesting historical rtsume of the 
work that had been done in late years, more especially under 
the anspices of the tropical diseases committee of the Royal 
Society. This work was divided into experimental, epidemio¬ 
logical, and prophylactic. Under the first head he instanced 
the work of Horrocks, Shaw, himself, and others on the life- 
history and identification of the micrococcus Melitensis and 
its recovery from the blood and other secretions, and also 
experiments directed towards discovering the channels by 
which infection was conveyed in this disease. Under the head¬ 
ing of epidemiology were mentioned the reports of Davies 
and Johnstone, and under prophylaxis the work of Eyre and 
Shaw on sera, antisera, and toxins. The most important 
points brought out step by step were : (1) the great vitality 
of the organism outside the body when not exposed to direct 
sunlight; (2) the constant presence of the organism in the 
peripheral blood of cases suffering from the disease ; (3) the 
escape of the organism from the body chiefly through the 
wine; (4) the presence of the infective organism in the 
urine of apparently healthy men ; (5) frequent infection of 
domestic animals, chiefly goats ; (6) infectivity of the urine 
and milk of these animals ; (7) the high incidence of cases in 
patients and Btaff of hospitals ; (8) the high incidence in 
officers, women, and children; (9) occurrence of localised 
epidemics ; (10) rare recovery of the organism from local 
mosquitoes and very donbtfnl possibility of their being dis¬ 
tributors of the disease; and (11) complete cessation of 
cases where Infected milk was removed from the dietary or 
when it was properly sterilised. The prevention of the 
disease by “protective inoculations” still remained tub 

justice. As regards treatment he had little to say in favour 
of antisera or vaccines, though in chronic cases the latter 
seemed to have some slight beneficial effect. No specific 
drug had yet been discovered, quinine in large doses was 
harmful, cyllin was disappointing, fresh yeast was inoperative, 
and quinine combined with chlorine water was very uncertain 
in its results. Symptomatic treatment might, however, do 
much to relieve the insomnia and the persistent neuritis of 
the later stages. For this Fleet-Surgeon Bassett Smith 
recommended salicylate of quinine, while arsenic and 
iron were of use in the later cachexia and strychnine 
for irritable heart should this be a seqneia. Touching 
briefly on pathology he pointed out that the evidence 
in favour of a general septicemic infection was very 
strong, the organism being recoverable not only from the 
peripheral blood but also from the internal organs. In one 
case he had known an infective endocarditis to develop. 
Local lesions also occasionally occurred, sometimes in the 
form of soft fluctuating swellings, not containing pns bat a 
turbid fluid from which the characteristic organism could be 
isolated. Ulceration of the small intestine and enlargement 
of the liver and spleen in chronic cases were also found. 

Lieutenant-Colonel VV. B. Lkisiiman, R A.M.C., considered 
that it was very desirable that investigation should be 
directed towards ascertaining the line of communication 
from diseased to healthy goats. He suggested that the 
disease might be attacked by immunising these animals by 
means of injection of attenuated cultures of the micrococcus, 
pointing out that good results had been achieved by this 
method in other diseases—e g., in cholera by Haffsine and 
more lately by Strong of Manila in the case of plague. 

Lieutenant-Colonel A. M. Davies, R.A.M C., quoted 
instances which inclined him to doubt whether milk was 
the only source of infection in this disease, and thought 
that the mosqnito might still be found to play a part in 
its dissemination. 

Lieutenant-Colonel D. V. O'Connell, R.A.M.C., was 
inclined to agree with the former speaker. He considered 
opium and morphine as being of great value in treatment-bat 
condemned the bromides as useless. 

Fleet-Surgeon Bassett-Smith, in replying, said he 
thought that the Maltese would raise no objection to 
immunisation experiments amongst goats if threatened 
with destruction of infected animals. He thought that the 
remarkable success of the Malta Fever Commission was a 
strong argument in favour of experiments on animals, since 
without these the work of the Commission could never have 
been carried out. 

The President then proposed a vote of thanks to Fleet- 
Surgeon Bassett-Smith for his interesting paper, which 
was carried by acclamation. The proceedings terminated 
with an exhibition of objects of interest in the Pathological 
Laboratory of the Royal Army Medical College. 


Exhibition of Cases and Specimens.—Plastic Roentgeno¬ 
graphy.—Method of Inflation of the Bladder with Oxygen. 
—Life History of Leucocytes. . 

A meeting of this society was held on Dec. 12th, 1907, 
Mr. Frank T. Paul, the President, beiDg in the chair. 

Dr. G. G. Stopford Taylor and Dr. F. P. Wilson 
showed a specimen from a case of Enchondroma Cutis.— 
Dr. Wilson stated that the specimen had been taken 
from a female child. The mother had had a haemorrhage 
during pregnancy and had been delivered a month before full 
time. When the child was about five months old the 
mother noticed a bluish stain on the inner side of the left 
leg just above the knee. This gradually developed into a 
hard plate. Similar plates subsequently appeared in the 
skin of other parts of the body. The specimen shown was 
taken from a plate over the right costal arch. It was so 
calcified in parts that a considerable effort was required to 
cut through it with a scalpel. A microscopical examination 
showed that the epidermis was normal. The corium was 
somewhat thickened and contained sweat glands with 
rudimentary hair follicles. In the deepest part of the corium 
were large irregular blocks of cartilage containing small 
cartilage cells and fenestrated here and there by spaces filled 
with a vascular connective tissue. In parts the cartilage 
seemed to merge indefinitely with the fibrous tissue of the 
corium. Dr. Wilson then commented on the extreme rarity 


of enchondromata of the skin and the fact that none of the 
cases hitherto recorded resembled the present one which was 
remarkable for the number of the new growths.—Dr. 
Stopford Taylor said that clinically the disease was one 
of cartilaginous plates imbedded in the corinm at various 
depths, and that in one plaque on the outside of the left 
thigh distinct ossific spicules could be seen and felt, 
stretching the epidermis—Dr. R. W. MacKenna said that 
the plaques were distinctly cartilaginous but were undergo¬ 
ing ossification. The condition was an extremely rare one 
and he had only been able to find one similar case in 
literature which was associated with fragilitas ossium 
and which ultimately degenerated into sarcoma.—Dr. 
F. H. Barbxdt believed the tumour to have originated 
in the subcutaneous tissue and to have grown into the cutis 
vera. The fact that the corium was implicated in the 
growing ends supported this view, as well as the islets of 
sweat glands and adipose tissue embraced by the tumour. 
He regarded the tumour as bony in nature and thought that 
there were distinct appearances of attempts at a Haversian 
system. Other portions of the section no doubt favoured 
the cartilaginous view which Dr. Wilson and others held. 
Possible dislocation of temporary cartilage during the 
development of the bones was the primary source of this 
rare condition and subsequent ossification. 

Dr. Nathan Raw showed a specimen of Carcinoma of Both 
Suprarenal Glands and Root of the Left Lung.—Dr. A. G. 
Gullan said that he considered Dr. Raw’s specimen of bi¬ 
lateral carcinoma of the suprarenal organs of special interest 
and importance because, although the suprarenals had been 
almost completely replaced by new growth, the patient had 
not shown symptoms or manifestations of Addison’s disease. 
This case thus supported the view which he felt inclined to 
believe—i.e., that Addison’s disease was the result of tuber¬ 
culous lesions of the suprarenal and their sequelae and was 
sot due to other pathological affections of the organ.—Dr. 
Bradshaw said that in the case of a patient with malignant 
disease it was not an easy matter to determine whether the 
symptoms of Addison’s disease were present or not. Pig¬ 
mentation was not a constant symptom in Addison’s disease 
and the other symptoms of that condition, asthenic and 
gastric irritability, if they were met with in a patient known 
to be suffering from malignant disease in any part of the 
body would probably be looked on as symptomatic of the 
cancer and not as due to the special involvement of the 
suprarenal bodies. 

Dr. David Morgan read a note on Plastic Roentgeno¬ 
graphy and showed several photographs and lantern elides of 
this new method. He described fully the methods of pro 
ducing the plastic effect, for the discovery of which they were 
indebted to Dr. Bela Alexander of Kdsmdrk, Hungary. 

Dr. Morgan also demonstrated the Method of Inflation 
of the Blander with Oxygen for the purpose of diagnosis in 
vesical trouble and showed a photograph of stone in the 
bladder obtained by this method. The radiograph displayed 
the structure of the stone and the ontlines of the bladder 
with remarkable distinctness. The oxygen inflation Dr. 
Morgan considered to be of great value in elucidating obscure 
affections of the bladder. Owing to the transparency of the 
medium (oxygen) any irregularity of the vesical mucosa 
would be readily discernible. 

Dr. Raw showed a specimen of Tuberculosis of Fish.— 
Dr. R. K. Harcoukt considered that the proof was not 
sufficient to say that it was the tubercle bacillus, since the 
Ziehl-Neelsen acid fast staining acted in leprosy as well, 
and under the microscope it was scarcely possible to dis¬ 
tinguish between the two bacilli. Again, Jonathan Hutch¬ 
inson’s theory that leprosy was caused by eating uncooked 
pntrid fish might point to this being the bacillus leprae and 
not tuberculosis. 

The President showed specimens of Myeloid Tumours.— 
Dr. Harcourt stated that in the early part of the year he 
was shown a section from a tumonr of the lung which was 
said to be secondary to a myeloid tumonr of the lower jaw. 
As the section was certainly a myeloid growth these tumours 
must be considered to be more malignant than was generally 
taught, as some authors (e.g., Mr. J. BlandSutton) taught 
that they were so benign that they placed them in a separate 
class, the myelomata. 

Mr. 0. E Walkkr read a paper on the Life History 
of Leucocytes. He described how some of the leuco¬ 
cytes in the bone marrow of mammals passed through 
the meiotic phase—that is, the number of chromosomes they 
exhibited when dividing was reduced to one-half of the 

normal somatic number. He drew a comparison between 
this phenomenon and what happened in the case of certain 
cells in plants. He then went on to describe how in some 
leucocytes which had not passed through this phase granules 
were developed in the cytoplasm His observations upon 
the derivation of the granuhs in leucocytes were communi¬ 
cated in a paper sent to the Royal Society in July, 1906. He 
described a small coiled-up thread as arising in the archo- 
plasm of these leucocytes. This thread grew until it 
occupied tl e whole of the cytoplasm and completely 
surrounded the nucleus. It then broke up into a number of 
6hort segments which subsequently assumed an oval or a 
round shape. The bulk of the cells which had passed 
through the meiotic phase he described as being converted 
into red corpuscles in the bone marrow. He showed that 
the series of changes which he described as occurring in 
these reduced leucocytes were completely checked by 
what could be observed actually happening under the 
microscope in the case of the red corpuscle of amphibia, 
reptiles, and birds. He pointed out that the condition of the 
leucocytes which were reduced was exactly similar to that of 
the sexnal elements, in that these cells had gone through the 
necessary preparatory changes for fertilisation. In plants 
only a few of the cells which reduced ever conjugated with 
other reduced cells ; the bulk of them merely served a 
nutritive purpose. Thus the fact that the bnlkof the cells was 
converted into red corpuscles was just what happened in the 
case of many plants. He then described what he claimed to- 
be a process of fertilisation occurring among a few of the 
reduced leucocytes. Two adjacent leucocytes sent out 
processes from their nuclei which join, forming a tube. The 
contents of one nucleus then passed over through this tube 
into the other nucleus, leaving one cell with a unclear 
membrane devoid of linin and chromatin and the other witb 
a double complement. He showed that this process was very 
different from the destrnotion of one cell by another. The 
latter phenomenon was very common but seemed always to 
take the form of engulfment of the whole or part of the cell 
destined to destrnotion into the cytoplasm of another cell. 
The nsnal sequence was that one leucocyte or other kind 
of cell engulfed another bodily into its cytoplasm ; the 
engulfed cell was then gradually disintegrated, but was 
never taken into the nucleus but remained in the cytoplasm 
of the engnlfing cell. Here the absorption of the contents 
of one leucocyte nucleus by that of another seemed to involve 
the development of a special and complicated apparatus, 
formed in such a manner that the chromatin and linin of 
the one nucleus might be transferred directly to the other 
without any process of digestion by the cytoplasm being 
possible. Mr. Walker therefore concluded that the pheno¬ 
menon which he described was a process of fertilisation. 
From this he farther concluded that the leucocytes passing 
out of coordination with the soma lived as parasites npon 
the parent organism, and in themselves possessed a complete 
life cycle. 


Hamatoma of both Broad Ligaments—Gonorrhoea and 
Uterine Sepsis —Cersarean Section for Petrie Deformity .— 
Diffuse Adenoma.—Primary Unilateral Superficial papil¬ 
loma of the Uvary.—Supports of the Pelvic Viscera. 

A meeting of this society was held at Manchester on 
Dec 20th, 1907, Dr. E. O. Cruft (Leeds), the President, being 
in the chair. 

Dr. \V. Walter (Manchester) related a case of Haema- 
toma of both Broad Ligaments occurring a few hours alter a 
supravaginal hysterectomy on a patient, aged 37 years, who 
was exhausted by prolonged metrorrhagia. The tumour grew 
from the posterior wall of the uterus and extended laterally 
to the sides of the pelvis. Incising the uterus deeply the 
myoma was enucleated from its attachments but general 
oozing from the broad ligaments gave trouble. The pulse 
was 84 at the completion of the operation, four hours 
later it was 96, and at 6 p.m. it was 116 and a small 
amount of blood was coming through the vagina. At 
8 p.m. the patient became collapsed and complained 
of abdominal pain. Saline injections were giveD, ether 
was administered, and the abdomen was opened. Not 
more than eight ounces of free blood were found in the 
abdomen, but both broad ligaments were distended with 

The Lancet,] 


[Jan. 4,1908. 23 

blood and clots. There was no bleeding apparent from the 
main vessels nor had their ligatures slipped. The collapse, 
simulating extensive haemorrhage, was the chief interest 
in this case and may have been doe to intense pain from 
over-distension of the ligaments in a patient already 
■debilitated by previous haemorrhage. Particulars were also 
given of a case of Abdominal Distension arising the day 
after supravaginal hysterectomy had been performed on a 
single woman, aged 40 years, who sought relief on account 
•of excessive menorrhagia and retention of urine, produced by 
a myoma. The operation took place on Oct. 29th in the 
Trendelenburg position. Three hours afterwards the pulse 
was 88 and the patient was fairly comfortable. On the day 
following the abdomen was slightly distended and flatus 
could not be passed voluntarily. The pulse gradually rose 
and in the evening it was 130; vomiting and pain were 
troublesome and nutritive enemata were no longer retained. 
On the third day symptoms were more pronounced and the 
pulse was 152. It was decided to open the abdomen unless 
some improvement took place. At 8 p m. one of the enemas 
took slight effect and the pulse fell to 140 and on the next 
day it was 128. Hot fomentations and gentle massage aided 
the ordinary treatment by enemata and calomel. The 
obstruction was possibly due to a kinking of the intestine 
when being replaced after Trendelenburg’s position. Both 
cases made good recoveries. 

Sir William J. Sinclair (Manchester) mentioned a case 
of Gronorrhcea and Uterine Sepsis occurring in a patient aged 
28 years, who had been married for seven years and had had 
one abortion. Curettage and removal of the uterine 
appendages had been previously carried out. The patient 
aought bis advice for constant abdominal pain and on 
Nov. 15th he extirpated the uterus per vaginam. Steady 
and continued improvement followed. He advocated con¬ 
servative measures from the outset in these cases. 

Dr. J Lloyd Roberts (Manchester) related two cases in 
which he had performed Casrarean Section for Pelvic 
Deformity. In one the patient had had eight pregnancies. 
'Craniotomy had been necessary five times and premature 
labour was induced twice, the child being stillborn on both 
occasions. Four years ago Caesarean section was successfully 
performed and now for the second time. It was interesting 
to note that there was no union between the uterus and the 
parietes following the first operation. In the second case 
oraniotomy had been performed once. Both patients made 
uneventful recoveries. 

Dr. Arnold W. W. Lea (Manchester) narrated two cases 
of Diffuse Adenoma occurring in Fibroid Uteri and drew 
attention to the features of pathological interest in this 
condition. Multiple polypoid projections of the endo¬ 
metrium, microscopically of a benign character, were present. 
The uterine wall was uniformly thickened to the extent of 
two inches in some situations. The specimens and micro¬ 
scopical sections were also shown. 

Dr. E. Emrys Roberts (Liverpool) gave a pathological 
report, illustrated by lantern slides, on a case of Primary 
Unilateral Superficial Papilloma of the Ovary and expressed 
the view that the ascites present in such cases was the result 
of secretion by the epithelium covering the papillm. The 
tumour was removed by Professor H. Briggs in the Hospital 
for Women at Liverpool. 

Dr. John Cameron (Manchester) exhibited a number of 
dissections demonstrating the Supports of the Pelvic Viscera. 
After pointing out that the muscles forming the pelvic floor 
in man were now recognised as vestigial structures he 
directed attention to the fact that they must regard the 
fascia surrounding the visceral branches of the internal iliac 
vessels (the perivascular fascia) as forming the most 
important support of the pelvic viscera both in the male 
and in the female. He then went on to suggest that opera¬ 
tive treatment for prolapsus uteri must be directed not to 
the pelvic outlet alone but also to this perivascular fascia. 


Section of Medicine. 

Diphtheritic I'ever.—Eye Strain. 

A meeting of this section was held on Dec. 6th, 1907, Dr. 
A. R. Parsons being in the chair. 

Sir John W. Moore gave details respecting a remarkable 
Outbreak of sore-throat which had come under his observation 

in a large girls’ Bchool in Dublin during the autumn of 
1906 Bacteriological examination proved the outbreak to 
be due to an infection with a form of the Klebs-Loffler 
bacillus diphtheriae. The resulting illness failed to present 
the typical features of classical diphtheria—it might be 
described as “ diphtheroid,” and he had ventured to call it 
“diphtheritic fever.” From Oot. 2nd to Nov. 11th, 1906, 
out of a total of 43 girls in the school 18 were attacked— 
that is, 41 9 per cent. There were five distinct outbreaks. 
In the first, one girl sickened on Oct. 2nd ; in the second, 
one girl sickened on Oot. 10th ; in the third, two girls 
sickened on Oct. 19th, two on the 21st, two on the 22nd, 
two on the 23rd, and one on the 24th; in the fourth, one 
girl was attaoked on Oct. 28th, two on the 29th, one on 
Nov. 1st, and one on the 2nd ; and in the fifth, one girl was 
attacked on Nov, 7th (for the second time), one on the 8th, 
and one on the 11th. After this last date no further 
cases occurred for a long time. Diphtheria was carried 
home to the country in two instances by the girls when, 
nearly two months after their illness, the school broke 
up for the Christmas holidays. Nearly 12 months afterwards 
a little epidemic of a precisely similar nature occurred in 
the school. On Sept. 30th, 1907, three cases of sore-throat 
occurred in the school ; the patients were moderately 
feverish, with swollen tonsils and enlarged cervical glands 
but little or no exudation. A bacteriological examination, 
made by Dr. W. Boxwell on Oct. 1st, showed that the milder 
form of the diphtheria bacillus was present in considerable 
quantities in two of the three cases. In the third case— 
clinically the most severe—Dr. Boxwell failed to find it, 
probably because streptooocci and staphylococci were so 
numerous that they crowded out, as it were, the Klebs- 
Lofiier bacilli—a fact well known in true diphtheria. Lastly, 
the symptoms which by their more or less constant presence 
made np the clinical syndrome of diphtheritic fever were: 
(1) a more or less severe coryza ; (2) a moderate tonsillitis, 
usually one-sided, and unattended by high fever or by much 
exudation ; (3) thickly coated tongue and foul breath, the 
tongue desquamating as in scarlet fever; (4) a patchy or 
punctate rash on the roof of the mouth and buccal mucous 
membrane ; (5) swelling of the cervical lymphatic glands ; 
(6) a roseolar rash on the skin ; and (7) distinct desquama¬ 
tion (in three cases), the peeliDg being particularly marked 
on the hands. — Dr. T. P. O. Kirkpatrick said shat some¬ 
times 10 or 11 recruits came into Bteevens’ Hospital, 
Dublin, in one day from the Constabulary Depot, com¬ 
plaining of symptoms resembling those described by Sir 
John Moore. They usually recovered in a 6hort time. 
In no case bad there been any suspicion of membrane, and 
bacteriological examination showed no trace of the diph¬ 
theria bacillus in many cases. The organism in the majority 
of cases was some form of coccus. The condition was looked 
npon as ao epidemic of catarrh and in no case had the roseolar 
rash or enlargement of the cervical glands been observed.— 
Mr. John Burgess said that the recruits mentioned by Dr. 
Kirkpatrick were brought up from the country and were not 
used to the ordinary hygiene. They were given swimming 
lessons and kept in the water for half an hour or more. This 
chilled them and they complained of sore-throats.—Dr. J. M. 
Day said that it was not necessary to find a membrane 
to diagnose diphtheria. He had pointed oat in a paper 
some years ago that cases having soft tonsils, coated 
tongue, and enlarged glands had given the diphtheria 
bacillus on a swab. Diphtheria was much commoner 
in the city than people supposed and there were two main 
predisposing causes—namely, bad teeth and constipation. 

Dr. Kirkpatrick read a paper on Eye Strain as a Factor 
in the Production of Functional Neuroses. One patient to 
whom he referred had complained for years of recurrent 
attacks of migraine and though he made no complaint of 
his vision his condition was completely relieved by the 
correction of some faulty muscle balance of his eyes. Cases 
were also quoted to show the advantage of the correction of 
errors of refraction in the relief of persistent headache. A 
patient who had complained of severe and more or less per¬ 
sistent headache for nearly 15 years was completely relieved 
by the use of proper correcting glasses. 

Dr. Herbert C Mooney read a paper on Eye Strain, in 
which he expressed the opinion that the relation between 
headaches and errors of refraction was not as fully realised 
by physicians as it might be. He pointed out the part 
played by errors of refraction, accommodation, and the 
balance of the extrinsic muscles of the eye in the causation 
of headache, migraine, giddiness, and nausea, and said that 

24 The lancet,] 


[JAN. 4, 1908. 

headaches met with in young students were often wrongly 
put down to the quality or quantity of the illuminant instead 
of to some degree, often quite small, of astigmatism. 

Devon and Exeter Medico-Chirorgical 
Society.— A meeting of this society was held on Deo. 12th, 
1907, Mr. R. Coombe, the President, being in the chair.—The 
President showed a boy, aged about 12 yearB, on whom he had 
successfully performed the operation of Submucous Resec¬ 
tion of the Septum Nasi.—Dr. J. D. Harmer, house surgeon 
at the Royal Devon and Exeter Hospital, showed for Dr. 
J. Delpratt Harris a case of Actinomycosis of the Jaw. The 
patient, who was a girl aged 18 years, gave a history of three 
months’ illness. The whole of the left side of the face was 
swollen and brawny and the eyelids were oedematous. There 
were several sinuses, from which exuded thick, yellow, 
offensive pus. She could only separate her teeth a short dis¬ 
tance and was in a serious general condition, with quickened 
pulse and elevated temperature. She was by occupation 
a domestic servant in Exeter, but her father was a farm 
labourer and she was at home in the summer.—Dr. R. V. Solly 
showed a microscopic slide of the pus from the foregoing 
case, which exhibited branching mycelium but no clubs.— 
Dr. Solly read a paper on Leukemia. He began by report¬ 
ing the following cases which occurred in the Royal Devon 
and Exeter Hospital. The first patient was a man, aged 
34 years, who had served in the Marines and had been to the 
tropics but had never been ill there. There was a history of 
syphilis four years ago. The present symptoms were 
amemia, indigestion, and palpitation. The spleen reached 
nearly to Poupart’s ligament. The patient’s temperature 
was generally normal. The blood contained about 3.000,000 
red cells and 340,000 white cells per cubic millimetre, with 
40 per cent, polymorphs, 56 percent, neutrophile, and 2 2 
per cent, eosinophile myelocytes. The patient remained in 
the hospital for three months and was discharged unrelieved. 
The second and third patients were women, aged respec¬ 
tively 40 and 30 years; they both died within three months 
after coming under observation. The fourth case was one of 
acute lymphatic leukaemia, which was fully reported in 
The Lancet of June 23rd, 1906. The patient was a girl, 
aged 13 years, whose whole illness only lasted 14 days, 
and whose blood contained the enormous proportions of 
796,000 white cells per cubic millimetre with only 16 
per cent, polymorphs and 86 per cent, large and 11 
per cent, small lymphocytes. Dr. Solly commenced his 
paper by stating that the diagnosis of leukaemia was 
almost entirely dependent on the blood examination. 
It was necessary, however, that a differential as well as 
a total leucocyte count should be made, as cases of 
leukaemia occurred in which the total count of the white cells 
was little raised above normal, but the differential character 
of the leucocytes was profoundly altered. Acute lymphatic 
leukiemia might give all the appearance or an acute infection 
and might have to be diagnosed by the blood examination 
from such diseases as typhoid fever or general septicaemia, 
and as it was almost invariably rapidly fatal it was well to 
make a diagnosis as soon as possible. Conditions such as 
splenic anaemia and lymphadenoma, where the leucocytes 
were little changed, were diagnosed immediately from 
leukaemia by a stained blood film, and the same could be 
said of enlargements of the liver and spleen due to syphilis 
or malaria. Spleno-medullary leukaemia, lymphatic leukiemia, 
and pernicious aniemia should be considered together as 
arising from Borne dyscrasia of the blood-forming organs, 
and particularly of the bone marrow. Dr. Solly then 
referred to cases described by Leube under the name 
of leukamemia which exhibited the characters of leukiemia 
and pernicious anosmia combined. Dr. Solly gave it 
as his opinion that the most probable cause of per¬ 
nicious amemia and the ieukiemias was some toxin 
acting in the bone marrow and possibly produced in the 
inter tines, and causing in pernicious amemia megaloblastic 
degeneration, destruction of red cells, and some myelocy- 
tosis, and in the Ieukiemias myelocytosis or lymphocytosis. 
The view that it was an intoxication was supported by the 
fact that both infection by the bothriocephalus latns and 
saponin poisoning produced megaloblastic degeneration as 
in pernicious aniemia. In these cases no improvement was 
produced by exposure to the x rays. In one case the spleen 
became smaller and the number of leucocytes diminished 
but the patient became more amomic and shortly died. 
Dr. Solly suggested that the fresh bone marrow sandwich 
treatment as carried out by Dr. A. G. Gullan of Liverpool in 

pernicious amemia might be tried in leukaemia.—Dr. W. 
Gordon in discussing the paper remarked that he felt 
certain that the large lymphocytes of acute lymphatic 
leukiemia were not the normal large lymphocytes of the 
blood, as these leuksemio lymphocytes frequently showed 
quite different staining characteristics, the normal lympho¬ 
cytes having a dark nucleus and a lighter rim of protoplasm, 
while frequently in these abnormal lymphocytes of leukaemia 
the rim of protoplasm took the basic stain more deeply than 
the nucleus. 

Sheffield Medico-Chirurgical Society.— A 

meeting was held in the society's room in the University on 
Dec. 19th, 1907, Dr. R Gordon being in the chair.—Professor 
J. M. Beattie showed the more interesting recent additions 
to the museum. These were accompanied by microscopic 
specimens and included specimens from cases of Delayed 
Chloroform Poisoning, Haemochromatosis of the Liver in 
“ Bronzed Diabetes,” a Lung Full of “ Sand ” which the 
micro-section showed to be due to Calcified Corpora 
Amylacea, a section of the Liver from a case of Argyria 
showing Silver Deposit, Malaria Parasites, Lymphatic 
Leukiemia of the Kidney and Liver, a Kidney from a case 
of Hicmoglobinuria, Endothelioma of the Lung, and Fat 
Necrosis of the Omentum.—Dr. Arthur J. Hall showed 
specimens of Hiemorrhage into the Cerebellum and Cerebrum 
due to Purpura Hiemorrhagica, a Liver and Spleen Two 
Years after Epiplorrhaphy for Cirrhosis of the Liver, and 
other cases.—Dr. H. G. M. Henry showed a series of 
Cerebral Tumours and specimens from a case of Congenital 
Syphilis.—Dr. H. Leader showed Macro- and Micro¬ 
specimens from a case of Lympho-sarcoma.—Dr. W. H. 
Nutt showed a series of Skiagrams illustrating bron¬ 
chiectasis, thickened pleurae, pulmonary tuberculosis, renal 
calculi, Intrathoracic growths, tumours, foreign bodies, 
fractures, and one of a child with absence of cervical 
vertebra;.—Dr. A. Rupert Hallam showed a series of Skia¬ 
grams illustrating fractures, foreign bodies, pulmonary tuber¬ 
culosis, renal and ureteric calculi, and a stereoscopic view 
of a skiagram of the hand.—Mr. Arthur M Connell showed a 
series of Pathological Specimens and a number of enlarge¬ 
ments of Micro photographs which showed very clearly 
several varieties of carcinoma and perithelioma.—Mr. A. W. 
Cuff showed a Sarcoma of the Shoulder removed by Berger's 
Operation, a Renal Stone from Perforated Pyo nephrosis, Anal 
Fistnlie which had been dissected out, and other specimens.— 
Mr. H. Lockwood showed specimens of Cystic Kidneys.— 
Mr. R. J. PyeSmith showed a Glioma of the Brain 
with microscopic specimen.—Mr. A. Garrick Wilson 
showed a specimen of Calculous Nephritis in an Infant.— 
Dr. Fercival J. Hay showed an Equatorial Staphyloma 
of the Sclera, Glioma of the Retina, a Rare Tumour of the 
Optic Nerve (Primary Glioma), Hydrophthalmos due to 
Ophthalmia Neonatorum, and a specimen showing Perfora¬ 
tion of the Cornea and Mode of Infection of the Posterior 
Chamber.—Mr. Miles H. Phillips showed a collection of 
Gynaecological Specimens, consisting chiefly of those added 
to the museum during the year. There were six prepara¬ 
tions of ectopic pregnancy, two of early rupture of the 
isthmial sacs, two tubal abortions, a five-weeks unruptured 
gestation in a rudimentary horn, and a full term unruptured 
sac, apparently tnbal. Other important specimens illustrated 
"red degeneration” of a fibroid during pregnancy, abscess 
of the corpus luteum, cystic degeneration of fibroids, and a 
good example of a fibroid polypus of the vagina.—Dr. F. H. 
Waddy showed three interesting Uterine Moles from cases 
of Missed and Concealed Abortion and a Six-months Hydro¬ 
cephalic Foetus with Deficiency in the FingerB of One Hand, 
possibly due to intra uterine amputation. 

Clinical Society of Manchester. —A meeting 
of this society was held on Dec. 17th, 1907, Dr. H. R. 
Hutton, the President, being in the chair —The meeting 
was devoted to the exhibition of cases.—Mr. E. Stanmore 
Bishop showed four cases of Gastro-enterostomy. Two 
of these had been done for ulceration of the stomach, 
one for ulceration of the duodenum, and one for hyper- 
chlorhydria. One of these cases was that of a young woman 
who at the time of operation was much emaciated from 
constant vomiting and loss of blood. After operation she 
rapidly improved and gained three stones in weight in four 
months. In another symptoms of perforation had been 
noted a month previously. When the abdomen was opened 
the omentum was found adherent to a thickened ulcer in the 
anterior wall of the stomach. Posterior gastro-enterostomy 


wag done and the patient lost all previous symptoms and 
rapidly increased in weight. Mr. Bishop described the 
evolution of the operation and pointed out the drawbacks 
of the earlier methods.—Dr. J. A. Knowles Renshaw 
showed : 1. A case of Papilloma of the Larynx. The 
patient, a female, aged 30 years, had suffered from 
hoarseness for three years. There had been no cough 
or discomfort; during the last year the hoarseness had not 
been so noticeable. On examination a small pedunculated 
growth was seen arising from the lower surface of the right 
cord at the junction of the anterior and middle third. On 
phonation the growth rose above the cords. The improve¬ 
ment in the voice which had latterly taken place was due, no 
doubt, to the increase in length of the pedicle which allowed 
this free movement of the growth. 2. A case of Ethmoiditis 
and Ulceration of the Septum Nasi. The patient, a woman, 
aged 32 years, complained of obstruction of the right nostril 
and swelling over the right nasal bone, which she attributed 
to a blow on the nose eight months since. There was a large 
amount of infiltration in the ethmoidal region, the middle 
turbinal being especially thickened. Over the septal cartilage 
was a shallow irregular ulcer, on the anterior edge of which 
were several small masses of granulation tissue. Although no 
definite history could be obtained the general appearance was 
strongly suggestive of specific disease. 3. A case of Chorditis 
Tuberosa. The patient, a woman, aged 25 years, had over¬ 
strained her voice by talking amid loud machinery. The 
node on the left cord was much larger than that on the right 
and was semi-translucent, having the appearance of a small 
myxoma.—Dr. G. II. Lancashire showed (1) three cases 
illustrating Different Phases of Lupus Erythematosus ; (2) a 
case of Hereditary Syphilis in a girl, aged 14 years, rapidly 
responding to five-grain doses of iodide of potassium ; and 
(3) a case of Molluscum Confagiosum. The back had been 
covered with an enormous number of lesions. Cure had been 
effected within a fortnight by expressing the contents of the 
tumour and rubbing in a 40 per cent, resorcin ointment.— 
Dr. K. W. Marsden, Dr. C. H. Melland, and Dr. C. C. 
Heywood also exhibited cases. 

Nottingham Medico-Chirurgical Society.— 
A meeting of this society was held on Dec. 18th, 1907, Dr. 
L. W. Marshall, the President, being in the chair.—Dr. 
Thomson Henderson gave a lantern demonstration illus¬ 
trating some of his recent work on the Anatomy and Patho¬ 
logy of the Eye. He pointed out that the unity of patho¬ 
logical processes throughout the body was an important fact 
and pathological conditions in the eye obeyed the same laws 
that applied elsewhere. The only clinical or pathological 
differences observable resulted from the anatomical condi¬ 
tions peculiar to the eye as a special sense organ. After 
describing in detail the anatomy of the angle of the anterior 
chamber and the formation of the aqueous by the ciliary 
body it was demonstrated how the fluid drained away by 
Scblemm'8 canal assisted by the iris. By means of crypts on 
its surface the latter allowed the aqueous fluid to penetrate 
its stroma and so to come ‘nto d re< tcontai t with the veins of 
the iris. When the pupil contracted these crypts were widely 
open, but when it dilated these openings were closed and 
outflow by way of the iris was prevented. After demonstrating 
the venous connexions of bchlemm’s canal Dr Henderson 
discussed their bearing on glaucoma. He stated that the 
open network or cribriform ligament on the inner side of the 
venous sinus of Schlemm’s canal became thickened in this 
disease so that the interspaces were reduced and free outflow of 
the aqueouswashinderedandintraoculartensionraised. This 
thickening was a physiological process going on throughout 
life and only in its results was the effect pathological. In 
virtue of its crypts the iris was an absorbing surface and the 
operation of iridectomy produced a large crypt—namely, three 
sides of a square, through which the aqueous readily escaped, 
as the cut surface of the normal iris never healed. The reason 
for this apparently startling fact was clear when they con¬ 
sidered that cicatrisation was a protective process, resulting 
from the reaction of the cells of a tissue to irritation or to 
altered conditions of life. As a successful iridectomy did 
cot alter the relation of the severed tissue cells to their 
immediate surroundings but left them still bathed by the 
aqueous, no stimulus was imparted to them to cause them to 
lay down a dense and protective layer. The iris tissue thus 
remained unaltered and presented a large raw surface, by 
means of which the aqueous could readily drain away pro¬ 
vided the operation was done before atrophy and damage to 
its structure had proceeded too far.—The subject was dis¬ 
cussed by Dr. F. H. Jacob, Dr. E. C. Kingdon, Dr. J. Watson, 

Dr. T. D. Pryce, and the President, and Dr. Henderson 

^sculapian Society.— A meeting of this 

society was held on Dec. 20th, 1907, Dr. W. Langdon Brown, 
the President, being in the chair.—Mr. Peter L. Daniel read a 
paper on Common Urinary Diseases and Some Points in 
their Etiology and Treatment. In the early stage of acute 
infection of a first attack of gonorrhoea the only germ present 
was the goDococcus. At the end of four or five weeks the 
infection of the gonococcus subsided and the urethra 
became aseptic and continued so for eight or ten days, but 
if not treated properly it got infected by streptococci and 
staphylococci which caused gleet. In the early stage 
of gonorrhoea the urine should be kept acid so as to 
inhibit the growth of the gonococci and prevent their 
spread from the anterior to the posterior urethra. For 
this the best drugs were urotropine or helmitol, and 
acid sodium phosphate, together with some preparation of 
sandal wood oil. The amount of liquids should be restricted 
so that drugs were given in a concentrated form. Local treat¬ 
ment should be started at once by injecting the anterior 
urethra alone, using a two-drachm Herring’s syringe with solu¬ 
tion of silver nitrate, 1 to 12 000, or potassium permanganate, 
1 to 8000. Stricture was not produced by gonorrhoea itself 
but by added sepsis, so the secret of treatment was cleanliness. 
Enlarged prostate in roost cases was the result of sepsis 
in the urethra. All other symptoms except difficulty in 
micturition and nocturnal frequency were due to sepsis 
setting up cystitis. Hence in enlarged prostate the cystitis 
should be treated. In kidney troubles, in order to get 
specimens of urine from different kidneys it was not neces¬ 
sary to catheterise the ureters, for a segregation answered 
perfectly well. Most kidney troubles were due to infection 
passing up along the “open door,” so if the lower genito¬ 
urinary tract was kept clean there would be less kidney 
mischief.—Dr. Herbert T. Herring said that nearly all urinary 
surgery was due to sepsis introduced by examination with 
dirty instruments. In treating a septic disease like gonor¬ 
rhoea it was essential that instruments, hands, and penis 
were aseptic so as to prevent any fresh infection. It was 
almost impossible to get formation of phosphatic stones 
without sepsis. 

South-West London Medical Society.— A 
meeting of this society was held on Dec. 11th, 1907, Dr. 
A. D Itoe, the President, being: in the chair.—Dr. Hector 
Macker zie read a paper on the Treatment of Pneumonia and 
its Complications. After defining pneumonia as a local 
infection of the lung by the pneumococcus, accompanied 
or followed by the entrance of the microorganism 
into the blood-stream, Dr. Mackenzie emphasised the 
importance of an abundant supply of fresh air in the treat¬ 
ment of all cases. In the past there had been three main 
forms of treatment, each of which had been successful in a 
measure: by bleeding, by brandy, and by the expectant 
treatment. The use of alcohol as a routine treatment was 
diminishing, but there were cases, especially amorg the old, 
where alcohol was of great benefit. Though bleeding was 
now out of fashion it was indicated in cases of marked 
cyanosis with cardiac dilatation; leeches, a dozen or more, 
might be employed in its place. Where there was prune- 
juice expectoration indicating oedema of the lungs and a 
watery condition of the blood calcium chloride should be 
given; in other conditions citrates were more useful. 
Oxygen had been much administered and greatly overrated, 
but it did no harm if no good. As to local applications, Dr. 
Mackenzie preferred hot to cold for the relief of pain. Sleep¬ 
lessness was best met by veronal or trional. With regard to 
the serum treatment, there was no evidence of any good 
result. The vaccine treatment was more encouraging, bnt 
there was much work to be done before any definite con¬ 
clusion could be reached.—The paper was discussed by the 
President, Dr. B. Baker, Mr. E J. Pritchard, Dr. E. C. 
Lambert, Dr. M. Mackintosh, and Mr. T. A. Howell. 

Medico-Legal Society.— A meeting of this 
society was held on Dec. 17th, 1907, Mr. Justice Walton, 
the President, being in the chair.—Dr. W. A. Brand 
showed to the meeting a “ Bill of Mortality,” dated 
1800, which referred to the number of deaths which 
had occurred in the various London districts for one 
week.—The President referred to the fact that 23 execu¬ 
tions were chronicled but the burials of only 11 were 
recorded, the probability being that the other bodies were 
sent to the anatomy schools.—Mr. E J. Blackett read a note 

26 The Lancet,] 


[Jan. 4, 1908. 

on a case of Drowning of a Newly-born Child, and Mr. D. 
Cotes-Preedy brought to the notice of the meeting a case of 
manslaughter tried at the last Stafford summer assizes, the 
deceased’s death following a fracture of the thyroid cartilage. 
—Dr. T. Claye Shaw read an interesting paper on the Radical 
Care'. Certification of Inebriates.—In the discussion that 
followed Dr. F. W. Mott, Dr. Charles A. Mercier, Dr. 
F. J. Smith, Dr. James Scott, Dr. W. Scott Tebb, and the 
President took part.—The President remarked that no 
judge with experience of criminal work could be of any 
other opinion than that so far as crimes of violence were 
concerned drink was generally the cause. As to whether 
drunkenness led to crimes of dishonesty his impression was 
that it was not the primary cause but that drink prevented 
efforts of reclamation. Dr. Claye Shaw seemed to have 
found fault with the criminal law, but he (the President) felt 
sure that the criminal law would never deal with inebriates 
as inebriates. The criminal law of this country did not 
punish habits but only specific acts. 

anb States 

A 8ystem of Medicine by Many Writert. Elited by Thomas 
Cufford Allbutt, M.A., M.D. Cantab., LL.D., D.Sc., 
I.R O.F, Lond., F.R.S., F.L.8., F.S.A., Regius Professor 
of Physic in the University of Cambridge, &c. ; and 
Humphry Davy Rollkston, M.A., M.D. Cantab., 
F.K.C.P. Lond., Physician to St. George's Hospital, ka. 
Vol. III. London: Macmillan and Co., Limited. 1907. 
Pp. 1040. Price 25s. net. 

The preface to this volume tells ns that ‘ 1 as regards the 
more Important articles [it] is a re-written rather than a 
revised snccessor of Vol. III. of the original edition ” and 
uuch is indeed the case. In the opening article on Rheu¬ 
matoid Arthritis Dr. A. E. Garrod now distinguishes two 
separate affections which he calls respectively rheumatoid 
arthritis and osteo-arthritis, a distinction which has recently 
been emphasised by the researches of a special committee 
at Cambridge. Spondylitis Deformans also receives separate 
consideration. The article on Gonorrhoeal Rheumatism is 
now amplified into one on various infective lesions of joints, 
dysenteric, syphilitic, pneumococcal, and so forth. An 
article on Intermittent Hydrarthrosis is also new. Dr. H. 
Batty Shaw now writes on Pulmonary Osteo-arthropathy in 
place of Mr. A. A. Bowlby who is still, however, responsible 
for the sections dealing with Osteitis Deformans and Mol- 
lities Ossium. Dr. F. J. Poynton, who now assists Dr. W. B. 
Oheadle in the article on Rickets, contributes a new section 
on Achondroplasia which is illustrated by two good repro 
ductions of photographs. 

The article on Gout, written by the late Sir W. Roberts, is 
revised by Dr. J. Rose Bradford who gives some account of 
recent investigations on the purin bodies and their relation to 
the disease. We cannot help thinking that one or two graphic 
formulas would have made this part of the subject clearer to 
those who have not specially studied the chemistry of 
these Bubstances. Professor R. Saundby’s article on Diabetes 
Mellitus is not much altered but the author now admits the 
possibility of a failure of the tissues to utilise sugar as part 
of the explanation of the condition, holding that “failure of 
the glycogen reservoir in the liver and reduction of the power 
of the tissues to consume sugar” together constitute “an 
adequate hypothesis of diabetes." The discussion of the 
relation of the pancreas to this malady is not very full 
and Cohnheim's hypothesis as to the interaction of the 
pancreas and the muscles is not mentioned. Dr. Rose 
Bradford is responsible for the section dealing with Diabetes 
Insipidus and apparently favours a nervous theory of the 
condition. Meyer’s views as to the inability of the kidneys 
to excrete the salts of the blood except in extreme dilution 
(hyposthenuria) are not apparently thought worthy of 
notice. The senior editor’s contributions on Sea-sickness 

and Mountain-sickness are now transferred to the division 
embracing General Diseases of Obscure Origin, where they 
are better situated than among ailments of the alimentary 
canal. Diseases of the Mouth are now intrusted to Mr Walter 
G. Spencer, while the most noteworthy alterations in the 
division dealing with diseases of the alimentary canal arise 
from the division, among other contributors, of the large 
proportion of work originally allotted to Sir Frederick 
Treves. Thus the subject of Enteroptosis, now disfigured 
by the name of visceroptosis, a barbarous hybrid term, is 
dealt with by Dr. A. Keith, while Appendicitis—this name 
having prevailed over the more correct perityphlitis—is 
intrusted to Mr. C. B. Lockwood, whose article is full of 
excellent matter if the style is not quite equal to that of his 
predecessor. Intestinal Obstruction is fully dealt with by 
Mr. H. L. Barnard, and Acute Peritonitis, as well as other 
affections of the peritoneum, is in the hands of Sir W. H. 
Allchin. A new section on Shock has been contributed by 
Dr. T. G. Brodie ; this condition is looked upon by the author 
as one of depression of the nervous centres. We are not 
quite sure of bis meaning when he attributes this to “an 
inchoate and excessive series of impulses ” (the italics are ours) 
which act on many parts of the cord simultaneously. The 
late Dr. W. S. Playfair’s article on Diagnosis of Abdominal 
Conditions from a Gynrecological Standpoint is omitted in 
the present edition, presumably as being more suited to the 
companion volume edited by Professor Allbutt, with the 
assistance of Dr. T. W. Eden. Lardaceous Disease is also 
treated of elsewhere in the present edition. The section on 
Diseases of the Anus and Rectum, originally written by the 
late Mr. Herbert Allingham, has been revised by Mr. J. P. 
Lockhart Mummery who has added some coloured illustra¬ 
tions of appearances seen through the sigmoidoscope. The 
late Dr. Dreschfeld’s revision of his articles on Gastric and 
Daodenal Ulcer was fortunately finished by the author 
before his death and these represent perhaps the last con¬ 
tributions made to medical literature by this distinguished 
physician. New sections which deserve notice are that on 
Congenital Hypertrophy of the Pylorus, written by Dr. 
G. F. Still, and thit on Subphrenic and other forms of 
Peritoneal Abscess from the pen of Dr. T. D. Acland, which 
replaces the original contribution of Dr. Lee Dickinson. 

The present volume well maintains the credit gained by 
those which have previously appeared and there is every 
indication that the new “ System ” will retain the place secured 
by the former edition as the most popular standard medical 
text-book in this country. ItB 1040 pages are packed into a 
book of convenient size for reading, while the printing is 
excellent and singularly free from typographical errors. We 
are inclined to think that a rather more liberal allowance of 
Illustrations would be an advantage hut can understand the 
editor’s reluctance to sacrifice more space in view of the 
expansion which ten years’ increase of knowledge has 
necessitated in the total bulk of the work. 

A Text book of Embryology for Students or Medicine. By 
J. C. Heisler, M.D., Professor of Anatomy in the 
Medico-Cbirurgical College, Philadelphia. With 212 
illustrations, 32 of them in colours. Third edition. 
London and Philadelphia: W. B. Saunders Company. 
1907. Pp. 432. Price 13s. net. 

The first edition of this work appeared in 1899 and this 
may partly account for the following remarkable state¬ 
ment : ‘ ‘ Prior to the beginning of the present century, little 
or nothing was definitely known concerning reproduction and 
development.” Obviously the author has not revised this 
statement since the end of last century. The work is a plain, 
straightforward account of embryology—not in its widest 
sense but rather of human embryology. Very few 
authorities are cited and references to literature are practi¬ 
cally absent. The sources of the borrowed illustrations—which 

Thb Lancet,] 


[Jan. 4. 1908. 27 

are rmmerous, from the works of His, Bonnet, and others— 
are duly acknowledged. Here and there certain facts of 
comparative embryology are given but the work is essentially 
one on human embryology adapted for students. The author 
follows the natural order in his treatment of the subject, 
beginning with the sexual elements and their physiology and 
passing on to segmentation of the ovum, germ layers, and 
the beginning differentiation of the embryo, the formation 
of the body wall, intestinal canal, and the foetal membranes, 
placenta, and umbilical cord. Then there is the more 
detailed description of the development of the external form 
of the body, its connective tissues and lymphatic system ; 
and subsequently there is set forth the story of the develop¬ 
ment of the face and mouth, the vascular, digestive, respira¬ 
tory, genito-urinary, cutaneous, nervous, and muscular 
systems ; and lastly, the development of the skeleton and 
limbs. With His he takes three stages of intra uterine de¬ 
velopment—the stage of the “ovum,” then that of the 
“embryo,’’beginning at about the fourteenth day ; the events 
from day to day are traced but the fourth week marks the 
most active growth of the embryo ; and finally, the 6tage of 
the “foetus,’’which comprises the time between the beginning 
of the second month and the end of pregnancy. The events 
that make up this period are described in order. The 
descriptions of development of the various organs are clear 
and not too long. Though the skeleton is taken last, and 
although it is the framework of the body in the anatomical 
or mechanical sense, it is not so embryologically. Its 
development is not begun, at least, not to any important 
extent, until all the principal organs are well differentiated, 
and its growth is largely subsidiary to that of the structure 
which it supports and protects; hence the story of its 
development naturally comes in at the end. 

There is an elaborate tabulated chronology of development 
running to several pages, setting forth in parallel columns 
the chief events in the development of the human emtryo 
from week to week and month to month. The work is, as we 
have already said, a plain, straightforward account of the 
human embryology for students of medicine rather than for 
those studying embryology from the point of view of science. 

The Nervous System of Vertebrates. By J. B. Johnston, 
Pi. D , Professor of Zoology in West Virginia University! 
With 108 illustrations. London: John Murray. 1907. 
Pp. 370. Price 15». net. 

This work deals with the nervous system from a broad 
point of view and endeavours, we think successfully and 
succinctly, to trace its phylogenetic hisiory and to show the 
factors which have determined the course of its evolution. 
More especially is attention given to its functional relations. 
There is little of mere descriptive anatomy. The account of 
the phylogecy of the forebrain differs from that usually given, 
while the statement is made that the taste buds are 
developed in the entodermal lining of the pharynx. If this 
be so it establishes an exception to the statement that all 
nervous structures are derived from the ectoderm. 

The work is set forth under the following heads : general 
morphology, development, nerve elements and their func¬ 
tions, and the functional divisions, including the somatic 
afferent division, the visceral afferent division, general and 
special, and the somatic motor and visceral efferent divisions 
of the nervous system. Then follow a chapter on the 
sympathetic system and others on centres of correlation 
and the cerebellum, the evolution of the cerebral hemi¬ 
spheres, and the neopallium. 

The short description of the general morphology is 
excellent and the account of brains in fishes is suggestive. 
The chapter on development forms a natural and excellent 
corollary to the foregoing. As to the importance of 
cephalisation this has brought with it, or rather the pro¬ 
cess consists in the development of, special sense organs, 

consequent enlargement of the brain and the formation of 
a rigid cranium to protect these organs, the disappearance 
of certain muscle segments and a change in position and 
functions of other muscles—e.g., eye muscles, the reduction 
in the number of gills, and with this the disappearance of 
various nerves and somites, the shifting of position of 
various organs and nerve roots due to these changes, and, 
lastly, the great development of the higher centres. The 
experiment of Bethe on the nerve cells of the crab 
C-trcinas seems to show that nerve impulses can pass 
through the processes of a nerve cell without traversing the 
body of the cell itself. There is a careful but not captious 
analysis of the neuron theory and it is now admitted 
that the part of this theory which treats of the doctrine of 
contiguity is definitely disproved. The nervous system as a 
whole may be considered as a complex of neurons variously 
linked together into functional systems, representing at once 
the mechanism by which certain work is done and a record 
of the experience of the individual and the race. 

When treating of functional divisions of the nervous 
system the general plan of the body shows actions in rela¬ 
tion to the external world and those related to internal 
activities having to do with the processes of nutri¬ 
tion and reproduction—i.e., somatic and visceral. This 
scheme is admirably set forth and worked out in the brain 
of selachians and in man. In fact, these chapters are 
amongst the best in the book Anyone making a careful 
study of these systems—afferent and efferent—as set forth 
by Professor Johnston will find new light on the complex 
problems and cumbrous nomenclature of the mammalian 
brain. The cutaneous division, with the special sense 
organs in fishes and the differentiation of cutaneous and 
auditory centres and the cerebellum, are well worked out, 
and this is the case also with regard to the study of the visual 
apparatus and visceral system and its components. The 
description of the development and evolution of the 
sympathetic system is compactly set forth and the same 
may be said of the cerebellum, and here we may point out 
t^e fallacy of the statement that the cerebellar hemispheres 
of mammals are new formations not found in sub¬ 
mammalian classes. The hemispheres are formed first. 
Ti e evolution of the cerebral hemispheres is made plain and 
interesting. In connexion with the study of the neo¬ 
pallium the work of Golgi, Cajil, and Flechsig naturally is 
largely drawn on. There are references to literature at the 
end of each chapter and also short notes on laboratory work. 
The book is such as could only be written by a skilled 
zoologist. It contains many original observations. We 
strongly commend it to the study of the youDger zoologists 
and neurologists. _ 

Studies in Laboratory Work, By C. W. Daniels, 
M.B. Cantab., and A. T. Stanton, M.D. Tor. Second 
edition. London: John Bale, Sons, and Danielsson, 
Limited. 1907. Pp. 491. Price 16* net. 

A NEW edition of this excellent work for research in 
tropical diseases has been necessitated by the rapid 
advances which have been made in all branches of 
tropical medicine since the first was published. These 
advances have in the volume before us been considered and 
especially information as to the known carriers of disease 
has been added, including ticks, biting flies, and fleas. 
Dr. Daniels also has had the advantage of the cooperation of 
Dr. Stanton in the preparation of the volume ; the result 
has been to furnish the student of tropical medicine with a 
work thoroughly np to date. 

In their opening chapter the authors show how the medical 
man practising in the tropics can best cope with the dis¬ 
advantages entailed by the absence of the well-equipped 
laboratory which is usually found in European institutions. 
An excellent chapter then follows with reference to post¬ 
mortem examinations, the statements contained therein being 

28 Thb lancet,] 


[Jan. 4, 1908. 

only too familiar to those who have had experience in 
the dead house in the tropics. The all-important subject 
of the examination of the blood is next considered; 
the different varieties of the corpuscles are described, 
as well as the methods of making blocd Alms and the 
various particulars as regards staining. The succeeding four 
chapters deal with the question of the parasites found in 
the blood and here the student will find a very complete 
account of the organisms of malaria. The Leishman-Donovan 
bodies receive due attention, as do also the filarim. Certain 
properties of blood plasma and blood serum are then 
considered ; here Sir A. E. Wright's theory of opsonins 
finds due expression. The authors give a brief but quite 
satisfactory account of the blood-sucking dies, mosquitoes, 
ticks, and fleas, illustrated by some excellent drawings. The 
student of the subjects connected with malaria and yellow 
fever is taught how to dissect mosquitoes, whilst the eggs, 
larv;e, and pupas and their breeding places are demonstrated. 
Fleas, lice, bed bugs, and ticks are classified and described, 
after which the pigments and various forms of degeneration 
found in the tissues are dealt with. The subject of the 
parasites is finally concluded by an account of their presence 
in the tissues. 

The important subject of the faeces is considered and 
the various points requiring observation are laid down ; the 
method of examination of the various parasites contained 
therein is demonstrated. The chapter would, however, have 
been rendered more complete had the method of washing the 
dysenteric stools as laid down by the late Dr. E. Goodevebeen 
mentioned, for by this method the observer is enabled to 
determine better than by any other with which we are ac¬ 
quainted the condition of the affected bowel and the pro¬ 
gnosis that should be formed concerning the outcome of the 
disease. After that of the fceces comes the examination of 
the urine in which we note mention of Cammidge's researches. 
The volume concludes with the subject of bacteriology as 
practised in the tropics. Here the difficulties of the subject 
as experienced in these conditions are noted and an excellent 
table is given of the organisms of special interest as regards 
tropical countries. The last two chapters are occupied with 
the questions of measurements of the various eggs, parasites, 
and normal and abnormal cells, and with that of statistics in 
the tropics. 

The authors have placed at the disposal of the student of 
tropical medicine a mine of information without which he 
cannot be considered properly equipped. 

The Ttiintgen Bays in Medical Work. By David Walsh, 
M.D, Edin., Senior Physician, Western Skin Hospital, 
London. Fourth edition. London : Bailliere, Tindall, and 
Gox. 1907. Pp. 433. Price 15*. net. 

This work was one of the first, if not the first, of its kind 
to be published in this country, and that its publication was 
justified is well shown by the issue of a fourth edition. The 
general arrangement of the work is essentially the same as 
before. The first part dealing with apparatus has been again 
written, or rather rewritten, by Dr. H. Lewis Jones. All 
the essential details are fully gone into and it is refreshing 
to observe that the usual “ padding,” consisting of one or 
more chapters on elementary electrical physics, so commonly 
found in works of this kind, has been omitted. The second 
and major part of the work is devoted to the application of 
the x rays in medicine and surgery. The localisation of 
foreign bodies in both civil and military practice comes 
in for a very full share of attention and here, as in the other 
parts of the book, we note the superior character of the 
illustrations which go so far to elucidate a subject of this 
kind. Those prepared from radiographs by Dr. David 
Morgan of Liverpool are worthy of special mention In the 
purely medical section the author rightly insists on the great 
and valuable help which this agent is capable of giving in the 

diagnosis of thoracic disease. From an almost daily experi¬ 
ence of the method we can bear testimony to its value ; and 
the facility and speed with which an otherwise doubtful 
point can be satisfactorily settled are sufficient to impress 
the most sceptical. The closing chapters are devoted to legal 
medicine, anatomy, and physiology. We can confidently 
recommend the volume to all those who are interested in 
x ray work of any kind. 

Post-mortem Pathology: A Manual of the Technic of Post¬ 
mortem Examinations and the Interpretations to be Drawn 
Therefrom. By Henrv W. Cattell, A.M., M.D., some¬ 
time Pathologist to the Philadelphia, Presbyterian, and 
Pennsylvania Hospitals. Third edition, copiously illus¬ 
trated with coloured plates and figures. London and 
Philadelphia : J. B. Lippincott Company. 1906. Pp. 547. 
Price 18*. net. 

The third edition of Dr. Cattell’s book has been enlarged 
and very considerably improved. In our review of the first 
edition we commended the practical character of the work 
as a handbook for the post-mortem room but pointed out 
that the descriptions of morbid conditions were meagre and 
incomplete and that the literary style was marred by the 
abrupt and unfinished character of many of the sentences. 
In this edition we are glad to see these defects remedied. 
The description of the methods of post-mortem examination 
and the general account of the technique of the exa¬ 
minations, of the dissections necessary to expose various 
organs, and of the methods of section remain as 
before thoroughly practical, clear, and easy to follow. 
The copious illustrations, which are mostly reproductions 
from photographs, contribute in no small degree to the value 
of the book. Careful general descriptions of the manner of 
using the various instruments are included and many prac¬ 
tical hints are given. Where various methods are in use for 
the examination of special regions Dr. Cattell Is careful to 
describe them in detail and to indicate those which in his 
own extensive experience have given the best results or to 
point out the value attaching to each for any particular 

Among the chapters of special merit we may mention those 
devoted to the examination of the skull and the brain and to 
the investigation of the naso-pharynx, the eyes, and the ears. 
The descriptions of diseased conditions and morbid organs 
have all been considerably extended and improved, while a 
great deal of recent work has been incorporated in a form 
convenient for reference. The directions given for the 
preservation of tissues and for the bacteriological investiga¬ 
tion of post-mortem tissues are succinct and thoroughly 
useful. A chapter on post-mortem examinations of the newly 
born contains valuable information on the subject and like 
all those referring to matters of technique is copiously 
illustrated, while the sections devoted to restricted post¬ 
mortem examinations and to the restoration and preservation 
of the body afford highly useful accounts of those subjects, 
containing a great deal of practical advice. A section on 
weights and measurements given in English and metric 
figures leaves nothing to be desired, while that devoted to 
post-mortem examination of the lower animals gives a few 
general hints in regard to their performance in such 
mammals as the horse, ox, sheep, and dog, and also in 
birds. A very brief chapter on plant pathology is perhaps 
hardly necessary, as it includes but little of practical import¬ 
ance, although various suggestive lines of research are 
indicated. A long chapter headed “medicolegal sug¬ 
gestions ” we have read with interest, since it incorporates 
a considerable amount of the author’s personal experience 
as “ coroner’s physician ” in Philadelphia. 

Many useful references are appended to the text and it is 
a pleasure to recommend this book in its improved form as a 
valuable handbook for the student in the post-mortem room. 

Tbw Lancet,] 


[Jan. 4, 1908. ‘49 

or for the practitioner who is called upon to perforin exami¬ 
nations of the dead bod; for medico-legal or other purposes. 

Manvel Pratique ie Manage et de la Dymnastique Medical 
Sucdoue. ( Practical Manual of Manage and of Sneduh 
Medical Exercises.) By J. E Marfort. Third edition, 
with 111 figures in the text. Paris : Vigot Fiferes. 1907. 
PP 319. Price 6 francs. 

A well-illustrated handbook which shall be at once 
intelligible and of moderate size, describing in simple terms 
the general methods employed in massage and in the varions 
forms of exercises adapted to medical purposes, is likely to 
serve a useful purpose. The small book before us fulfils 
most of these requirements ; it is well written, abundantly 
and clearly illustrated, and is of convenient size. Though 
not a medical practitioner, the author has a general acquaint¬ 
ance with the anatomical and physiological facts necessary 
for a proper appreciation of the principles underlying the 
therapeutic application of massage and muscular exercises. 
Indeed, he strongly emphasises the necessity for adequate and 
sufficient training in the theory and practice of these 
methods, and declaims against the harmfulness likely to 
result from the application of them by those with but a few 
weeks or moDtbs of training. He points out that in Sweden 
a course of three years at the Royal Institute of Massage is 
necessary before a diploma is granted. He insists on the 
importance of the application of these therapeutic methods 
under medical supervision by skilled persons and refers to 
various injurious effects which may be induced by their 
injudicious application. 

The first section of the book opens with a chapter on the 
history of massage and of its recent developments and 
applications; another follows on general considerations 
relating to the uses and applications of massage and 
muscular exercises. The second part of the book deals 
with the technique of massage. The various processes of 
efflevrace, fcrasement, pltrissage, tapotement, ondvlatitms , 
and vibrations are outlined and very clear figures are 
given in illustration. Various mechanical vibrators are 
described, including one devised by the author. The appli¬ 
cation of massage to the body generally and to the various 
organs is next discussed and the position of the patient and 
the operator is clearly defined. In this section it seems to ns 
that unnecessary importance has been given to massage in 
gynsecological conditions. 

The third section of the book is devoted to medical 
gymnastics and in it the passive and active movements 
applied to the various muscular groups are described 
and illustrated by figures or diagrams. In connexion with 
the active movements the various respiratory exercises are 
given. In this section certain resistance movements are 
noted such as those recommended in the treatment of 
some forms of cardiac disease. The exercises used in the 
treatment of scolii sis are also described and figured. 

The fourth and concluding section of the work deals with 
the physiological actions of massage and of muscular move¬ 
ments and with the indications for their use in practice. 
This would have been more suitably written by a medical 
author or in collaboration with one. It includes supposed 
indications for the application of these methods in a very 
great variety of conditions. None the less, as we have said 
at the outset, this is a practical and handy little book on the 
subject of which it treats. 


Eneyclopcedia a/nd Dictionary of Medicine and Surgery. 
Vol. VI., Lumbar Region to Nephrotomy. London and 
Edinburgh: William Green and Sons. Fp. 562. 1907. Price 
15*. net.—The sixth volume of this valuable encyclopaedia o 1 
medicine and surgery contains more subject headings than any 
previous volume with the exception of the second. The subject 

most extensively dealt with is that on Diseases of the Lungs, 
but besides this long article there are 48 others of more than 
1000 words in length, as well as 82 of less than 1000 words 
and more than ten lines in length. The rest of the volume is 
made up of 1100 short paragraphs or definitions. Amongst 
the Various subjects dealt with we find an able article on 
Lunacy by Dr. J. F. Sutherland, In which the practitioner 
will find information on all the ohief points of the 
affections included under this term. Dr. R. W. Philip, 
Dr. S. H. Habersbon, and Dr. R. A. Fleming contribute 
the excellent section on the Lungs. The historical aspect 
of tuberculosis is well drawn. This is followed by 
the section on the etiology, pathological anatomy, and 
symptoms. Then we come to an excellent exposition of 
the physical signs of the various stages. The clinical 
varieties and complications are detailed and are followed 
by the diagnosis, prognosis, and treatment. Much 
information is given about the sanatorium treatment. The 
remaining diseases of the lungs are dealt with in an 
equally explicit manner. Dr. Norman Walker contributes 
an excellent article on Lupus Erythematosus. In his opinion 
we note that internal medication is rarely of much value. 
This is not, however, by any means universally held, as the 
salicylates have been found by other authorities to confer 
much benefit on the sufferer from this affection. Dr. 
G. Lovell Gulland gives a valuable contribution on the 
Physiology and Pathology of the Lymphatic System. The 
tabular statement of the glands showing the source of their 
afferent vessels and the destination of their efferent vessels 
is concise and complete. This is followed by a description 
of the different diseases of the lymphatic glands and their 
treatment. The article on Malaria, perhaps the best in the 
volume, is contributed by Mr. D. C. Rees. This writer gives a 
succinct accouut of the various steps whereby the mosquito 
theory was finally established. He then describes the 
biology of the malarial organism and the life-history of this 
parasite, which is illustrated by some excellent plates; the 
different species of the mosquito receive attention together 
with the development of the malarial organism in these 
hosts. The student is taught how to demonstrate the 
parasite, after which the clinical features of malaria are 
described with the various sequelae that may ensue. The 
sections on the morbid anatomy, the etiology, and the treat¬ 
ment, both curative and prophylactic, complete the article. 
Mr. T. D. Patmore writes exhaustively on the subject of 
malingering and gives many amusing instances of the 
manner in which malingerer were detected. Mr. H. J. Stiles 
discusses the Diseases of the Mammary Gland in an article 
which will well repay perusal ; this also is illustrated by 
some excellent plates. Dr. F. de Havilland Hall contributes 
a lucid article on the Diseases of the Mediastinum, whilst 
Dr. A. Mackintosh, Dr. G. F. Still, and Professor W. Osier 
deal with the matters connected with the meninges, describ¬ 
ing the anatomy, physiology, and vascular disorders of these 
membranes, and tuberculous, posterior basic, and epidemic 
cerebro-spinal meningitis. Amongst the other sections in 
the volume may be mentioned that on the Injuries and 
Diseases of the Mouth and Jaws, by Mr. H. P. Dean ; a very 
good article on Mycetoma, by Lieu tenant-Colonel W. Keith 
Hatch ; and lastly, an excellent contribution on Nephritis, 
by Dr. Nestor Tirard. This volume fully sustains the 
reputation of its predecessors. 

Manual of Praatical Anatomy. By D. J. Cunningham, 
M D. Dab. and Kdin., D.Sc., LL.D., D.C.L., F R 8.. Professor 
of Anatomy in the University of E linburgh. Vols. I. and II. 
Fourth edition. London and Edinburgh : Young J. 
Pentland. 1907. Vol. I., pp. 621 ; Vol. 11. pp 600. Price 
10* 6 d per volume.—The appearance of a fourth edition of 
Professor Cunningham's well known “Manual of Practical 
Anatomy,” besides affording conclusive proof of its 
popularity also points to the characteristic thoroughness 

80 The Lancet,] 


[Jan 4, L90S.' 

of the author in having once again brought his book up to 
date. The general plan of the work, which like its pre¬ 
decessors is still published in two volumes, remains un¬ 
altered but the text has been carefully revised and several 
parts, chiefly in the chapters relating to the abdomen and 
thorax, have been rewritten. A large number of new illustra¬ 
tions have likewise been added to both volumes. The figures 
depicting the right and left pleural chambers, as seen from 
the side after removal of the lungs and a portion of the 
chest wall, are particularly instructive and should be of great 
assistance to the student. In the section devoted to the 
heart the text is amplified by many excellent illustrations, 
one of which depicts the auriculo-ventricular bundle in the 
heart of a calf. The chapters on the head, neck, and brain 
are particularly good and leave nothing to be desired. No 
less than 30 new illustrations have been added to the second 
volume which deals with the limbs and abdomen, whilst the 
text in the latter section has been rewritten in many places. 
The account of the stomach, pyloric canal, and pyloric 
vestibule is very clearly given and is liberally illustrated. 
Though several pages are still devoted to the pelvic fascia we 
fear that the average student very seldom sees the many 
layers and ligaments which are so aptly described. 
Professor Cunningham’s “ Manual of Practical Anatomy ” is 
undoubtedly the beet work of its kind in the English 
language and thoroughly deserves all the success which it 
has gained. 

The “ Ideal ” Medical Diary and Visiting List. London : 
Langley and Sons. Price 7s. 6 d. in morocco cover ; visiting 
list refills, 3s 6d. ; duplicate prescription refills (50), 6ii.. or 
5s. 6 d. a dozen. Wellcome's Medical Diary and Visiting List , 
190ft .—We noticed the editions for 1907 of both these diaries 
fully in The Lancet of Jan. 26ob, 1907, p. 236. Similar 
diaries for 1908 have reached us in which the main features 
are repeated. The “Ideal” Diary is a neat and handy pocket- 
book and the removeable visiting list and blank prescrip¬ 
tion forms are distinctly serviceable. Messrs. Borroughs, 
Wellcome, and Co.’s Medical Diary and Visiting List is 
widely known and appreciated. 

Walker's Diaries. London : John Walker and Co., Limited.— 
We have received a selection of pocket diaries from Messrs. 
Walker and Co. which are of the accustomed quality of their 
annual publications. Those before us are in various bindings 
and of different prices, from an “ American Russian ” one 
page at an opening at 3i. 6<f., to a tiny “quarterly” waist¬ 
coat-pocket diary with refills at 1». Those with pigskin 
bindings are especially serviceable but all are well and 
neatly bound. 

The Poetical Works of Thomas Campbell. Pp. 400. Price 2s. 
The Poetical Works of Shelley. Pp. 928. Price 2s. The Ox’ord 
Edition. Oxford : Henry Frowde. 1907.—The above-men¬ 
tioned works are two more volumes of the admirable Oxford 
Edition of Poets, one volume of which—namely, the Keats— 
we reviewed recently. For one parson who knows the works 
of Campbell probibly 50 know those of Shelley, and although 
the former was not to be compared with the latter as a poet, 
yet some of his lyrics are among the finest things in the 
English language. The volume opens with “The Pleasures 
of Hope,” a poem which is quite up to the standard of the 
average Newdigate, but which, like all eighteenth-oentury 
didactic poems, irresistibly reminds one who has read the 
poetry of the Anti-Jacobin of the famous “ Loves of the 
Triangles.” This, however, was a youthful flight. Campbell’s 
real poetic genius is shown in “The Battle of the Baltic,” in 
“ Hohenlinden,” in his songs, and above all in that mag¬ 
nificent poem, “ The Last Man,” with that wonderful 

“ And ships wore drifting with the dead 
To shores where all was dumb/' 

Much may be forgiven to a man who could write like that, 

" The sunset sheds a horizontal smile," 

as he wrote elsewhere. Mr. J. Logie Robertson supplies an 
introduction and notes. As regards the “ Shelley,” which is 
edited by Mr. Thomas Hutchinson, who writes an introduc¬ 
tion, the reader finds here a complete collection of all the 
works of Shelley which have ’ appeared in print hitherto, 
including fragments. The Oxford University Press deserves 
great credit for making it possible for those whose purse 
is not deep to possess well-printed, well-edited copies of 
imperishable literature. 

The Explorer. By W. S. Maugham. London : W. H. 
Heinemann. 1908. Pp. 297. Price 6s.—When we reviewed 
Mr. Maugham's first book, namely, “ Liz * of Lambeth,” while 
giving him full credit for a clever book full of observation 
we ventured to hope that in future works he would choose a 
less sordid subject. This hope was fulfilled in a later book— 
“Mrs. Craddock”—and in the book now before ns he has 
risen to a greater height still. “The Explorer” is a fine 
study of two fine characters and, as is always the case, they 
are refined by suffering. Alec MacKenzie is by no means 
perfect, he makes mistakes and profits by them, but his course 
is ever upward, and at the end we leave him strong in the 
love of the woman who is everything to him and happy in 
the consciousness that he will return from an expedition full 
of danger. The minor characters are well drawn ar d no one 
in the book bores the reader. Altogether, “ The Explorer ” is 
a book to be read and epjoyed. 


The Journal of Balneology and Climatology , October, 
1907 the official quarterly of the British Balneological 
and Climatological Society). This number contains Dr. 
Norman Moore’s address on “Air, Water, and Sanita¬ 
tion,” which has appeared in our columns ; some notes 
on the Shropshire Highlands and the Wentnor Saline 
Water, by Mr. Norman Hay Forbes; a piper on the 
Relation of Temperature, Humidity, and Winds to Chronic 
Nephritis, by Dr. W. R. F. Phillips ; and a communication 
by Professor Victor Schmieden on Bier's Method of Treating 
Inflammations by Stasis and Hyperaemia. translated by Mr. 
Charles G. Levison of San Francisco. This is a very clear 
and able summary of the technique of applying Bier’s treat¬ 
ment by bandaging or suction or heat to the various parts 
of the body. It is entirely practical and does not touch on 
the principle underlying a method which is proving in¬ 
creasingly useful. The translation is able but we must 
protest against the term “stased limb” used throughout 
for a limb undergoing venous stasis. 

Proceedings of the Royal Society of Medicine , Vol. I., 
No. 1.—We have previously alluded to the format of the 
official journal of the Royal Society of Medicine, 1 which is 
edited by Dr. John Nachbar under the direction of an 
editorial committee representing the various sections of the 
society. The first number contains reports of the opening 
meetings of the various sections, including presidential 
addresses by Sir Thomas Barlow in the Clinical Section, a 
most interesting and stimulating review of the past work of 
the Clinical Society; by Dr. H. RadcUfife Crocker in the 
Dermatological Section ; by Mr. W. Deane Butcher in the 
Electro-Therapeutical Section on the Future of Electricity in 
Medicine, a fascinating forecast which has already appeared 
in these columns; by Dr. A. Newsholme in the Epidemio¬ 
logical Section on Poverty and Disease as illnstrated by 
the Course of Typhus Fever and Phthisis in Ireland, 
which is a very painstaking and exhaustive study; by 
Dr. Samuel J. Gee in the Medical Section; by Mr. 
J. Howard Mummery in the Odontologioal Section ; by Mr. 
S G. Sbattock in the Pathological Section ; and by Dr. T. E. 
Burton Brown in the Therapeutical and Pharmacological 
Section. The most noteworthy of the papers printed in the 

1 Thf. Laxcet, Dec. 7th, p. 1633. 

Tir* Lancet,] 


[Jan. 4, 1908. 31 

present '‘Proceedings” is probably that read by Professor 
E. Goldmann before the Surgical Section on “The Growth 
of Malignant Disease in Man and Lower Animals, with 
special reference to the Vascular System.” 3 There is a large 
number of interesting cases recorded, with abstracts of dis¬ 
cussions held on some of them, to which we need not further 
allude, as many of these cases have been recorded in our 

spurts and Jnalgtiral JUrords 




(Allen and Haniu rvs, Limit ed, 37, Lo.uuard-strekt, London, E.C.) 

“ Sauerin ’’ is described as a pure culture of a vigorous 
strain of bacillus acidi lactici prepared in tablet form for 
internal use and for the production of soured or curdled 
milk. We owe to Metchnikoff and others the discovery that 
an active strain of lactic acid producing bacteria inhibits the 
growth of the bacillus ooli communis and other intestinal 
bacteria in the colon by producing lactic acid. The 
suggestion, therefore, is that the active lactic acid pro¬ 
ducing bacillus might be given to act as a general intestinal 
disinfectant and might prove useful in disorders arising from 
a toxic process in which excessive intestinal putrefaction 
is involved. Already some evidence has been obtained that 
lactic acid is valuable in the direction indicated. We have 
submitted the sauerin tablets to experiment and have found 
that they are active in producing lactic acid readily when 
cultivated in milk kept at a blood temperature. The 
organisms, of course, attack the milk sugar, converting it 
into lactic acid. The milk so treated appears to present the 
lactic acid in a most active form for administration. The 
curdled milk can be Savoured with cinnamon, nutmeg, or 
other substance according to taste. The method suggested 
appears to be worthy of trial. 


(The Marmite Food Extract Co., Limited, Mincing-lane House, 
59, Eastcheap, London, K.C.) 

We have already submitted ordinary Marmite Food Ex¬ 
tract to analysis, but we have recently received a sample 
known as the Savoy Brand which is stated to be obtained by 
submitting the ordinary marmite to an additional process 
whereby it becomes more highly refined and also retaios 
the flavour of the fresh vegetables which are used in the 
process. The flavour, in our opinion, is certainly good and 
is barely distinguishable from good beef extract, yet marmite 
is entirely of vegetable origin. Our analysis, which prac¬ 
tically agrees with an analysis a copy of which has been 
Bent to us, gave the following results : moisture, 23 ■ 84 per 
cent. ; mineral matters, 19 • 78 per cent. ; and extractives, 
56'38 per cent. The extractives include over 2 per cent, of 
peptones and albumose, but for the most part the nitro¬ 
genous matters consist of bases, while the non-nitrogenous 
matters include lactic acid. The total nitrogen was 6*82 
per cent. The preparation serves the purpose of a stimulant 
in much the same way as does meat extract, while it also 
contains a definite proportion of real nutritives. 


(Dk Laaoe Fils and Co., Coonac. London AgencT: Noakes and 
Co., Limited, White's Grounds, Bermondset, S.K) 

Of the two samples of brandy submitted to ns one was 
described as “three stars ” and the other as 25 years old. 
Our analysis, especially In regard to secondary products, gave 
results identical with those given by genuine Cognac brandy. 
The ethers in both instances amounted to 100 parts per 
hectolitre, the furfural amounted to 1 part, and the bigtier 
alcohols to just short of 200 parts. The 25 year old brandy 

» The Lancet, Nov. 2ud, 1907, p. 1236. 

was more elegant In regard to taste and bouquet than was 
the “three stars.” It was, however, somewhat sweet to the 
taste. There is no evidence on analytical premisses that 
these brandies are not the genuine products of the Cognac 
district. They contain a notable amount of extractives and 
resinons matters derived probably from storage in wood. 


(Stavanger Prkserving Company, Norway, and Coronation 

House, 4, Lloyd’s Avenue, London, E.C.) 

Tbe sardine preserved in olive oil fills an important place 
in the dietary, since not only is it appetising but decidedly 
nutritious also. The Norwegian sardine is further submitted 
to a process of smoking which. In the view of many, adds con¬ 
siderably to its palatable qualities. The sardines at any rate 
of the above company are very agreeable to the palate and, 
so far as we can see, are prepared with care. We could find 
no evidence of metallic contamination either in the olive oil 
or in the fish. There was just a slight indication that the 
sardines prepared with tomato pur6e contained a trace of 
metal. This could be avoided by using varnished or lacquered 
metal when it is intended to pack the fish with an acid- 
containing substance such as is the pulp of the tomato. 


(The Colonial Planters, 154, Church-road, Hove, Sussex.) 

In our recent articles on Jamaica as a Health Resort we 
have alluded to the production of tea in that colony. We 
have since had the opportunity of submitting a sample to 
analysis, with the following results : moisture, 7 • 50 per cent.; 
mineral matter, 5 50 per cent. ; tannin, 8 22 percent.; and 
theine, 1 * 60 per cent. According to this analysis it is worthy 
of note that the tannin is decidedly less than that contained 
in either China or Indian tea, the average amount being 10 
per cent. The theine, however, occurs also in smaller quantity 
in Jamaica tea but this m-iy not be a disadvantage. The 
flavour of the tea is decidedly delicate, being free from the 
roughness of coarse teas ; it is, however, not so attractive 
to the palate as that of line oriental teas. 


(Walter Mitchell and Sons, Ayr.) 

We have received a cooked ham from which the bones 
have been removed, contained in a stout gelatin corton. 
The meat proved to be quite sound and it is said that this 
method of packing keeps it sound for months. The hams, 
we understand, have been supplied to the Royal Navy. We 
quite admit that this cover is an improvement on the tinning 
method provided that it protects the meat from undesirable 
changes. We found that the gelatin corton was impregnated 
with boric acid. The corton is known as the gelantiseptic 


(Bubroughs, Wellcome, and Co., Snow Hill Buildings, 
London, E.C.) 

This soloid is convenient for readily obtaining the black 
mercurial wash of the pharmacopoeia. One soloid powdered 
and shaken with one fluid ounce of water gives a lotion con¬ 
taining tbe same mercurial equivalent as the lotio hydrargyri 
nigra. By adding 24 minims of glycerine to the fluid ounoe 
the official preparation is more nearly represented, glycerine 
serving to prevent the black suboxide of mercury produced 
by the inter action of the lime and calomel from oxidising to 
yellow mercuric oxide. 

Jjtefo Indentions. 


The illustration depicts a portable hut designed and 
patented by Mr. Melvin of Glasgow. The floor, sides, ends, 
and roof are made of a strong wooden framework, the floor 
beiog covered with match boarding. All the parts are 
hiDg'ed in the centre, so that they can be folded and thus 
rendered easy to transport. The sides, ends, and roof a^e 

32 The Lanoet,] 


[Jan. 4, 1908. 

covered with a specially prepared waterproof canvas. The 
sides and ends are attached to the floor and to each 
other at the four comers by thumb-screws and sockets. 
The thnmb-screws can be unscrewed sufficiently far to 
release them from the sockets but cannot be entirely 
removed, thus obviating the danger of loss. The 
door and the two windows are hung on loose pin 
hinges and may be lifted off and hung, opened, and 
closed at will. The means for ventilation are good. The 
beds nsed in these huts are fixed somewhat after the 
manner of those in a ship's cabin and can be easily placed 

in position and taken down. The table, the hat and coat 
hooks, and other furniture are also designed so that they can 
be removed without difficulty. The sanatorium whioh we 
saw was 8 feet 6 inches in length and 6 feet 3 inches in 
width. When packed it occupied a space of 50 cubic feet 
and weighed three hundredweights. The advantages claimed 
for these huts over the ordinary huts or tents are that they 
are comfortable, they can be placed in position and taken down 
in a few minutes, and they are storm proof and well lighted 
and ventilated. The uses to which such buildings could be 
put are many and medical men will hardly require to have 
them pointed out. The London and export agents are 
Messrs. Stracban, Turner, and Oo, 37, Lime-street, London, 
Bf.C., from whom all particulars may be obtained. 

Xookino Back* 


THE LANCET, SATURDAY, Jan. 2nd, 1830. 

I received some of my medical education at Guy's 
Hospital ; 1 and at the time I was a pupil there, Dr James 
Curry, knowing the important share the liver had in disease, 
and the great use of mercury, rendered me an essential 
service by much that be taught; though for the liver, I now 
know that we ought to substitute the whole order of hepatic, 
gastric, and intestinal organs ; yet, to so absurd a pitch 
would he carry his views of the importance of the liver, 
that he would have had one believe that, in all diseases, the 
liver was importantly affected, and that the chief attention 
ought to be paid to it. I once saw a case of urethral 
stricture relieved by the warm-bath ; and in which, he said, 
the relief was obtained through the warm-bitti relaxing the 
biliary ducts, and that the stricture in the urethra became 
relaxed, merely by sympathy with their relaxation. The 
practice now so strongly recommended by Broussais in 
France, of withdrawing blood from the abdomen in fever, 
was always strongly inculcated by him; to me, Bioussais’s 
practice offers nothing new; it is what, owing to the 
instructions of Dr. Curry, I have all my life adopted ; that 
is to say, I always looked out for abdominal tenderness, and 
remedied it by local bleeding. Dr. Curry's error was, in 
contending that the liver was so peculiarly affected in fever, 
that the tenderness all around the region of the liver, was 
to be attributed entirely to disease of that organ ; whereas, 
it is the stomach and intestines, at least as much as the liver, 
that suffer. On his absurdity in mercurialising for every 
disease, as he positively did, I need not dwell. A surgeon, 

i Excerpt from Clinical Lecture by Dr. Blllotson, delivered at 
SW Thomas's Hospital. Fever.” 

now retired from practice, Baw, better than his surgical 
brethren, the utility of blue pill, and the importance of 
attending to the stomach and bowels ; but he was not content 
with exhibiting it where it was improperly neglec'ed by 
other surgeons; he gave it indiscriminately in any case, 
medicsl or surgical, and would generally not take the trouble 
to investigate a case, or even to look at a local affection, but 
at once called out, " The stomach, the bowels, are in fault, 
and blue pill must be taken so that with him, I have no 
hesitation in saying, as Dr. Macculloch does, at p. 55. that 
this was "an abuse, convenient to indolence, by superseding 
the necessity of thought or investigation, and by reducing 
the whole practice of physic to an empiricism to which 1 
know not that its entire history can pro lace a parallel 
example ” “ If the united ignorance and presumption,” 

Dr. Macculloch goes on to say, at page 163, “of self em¬ 
pirics could ever find an excnse, they might, indeed, claim it 
in this case, when they see practitioners of high fame, if 
notoriety be fame, following similar universal systems of cure, 
applying salts, or the blue piil, to every disorder or symptom 
in the nosologv, and without inquiry; and thus, while saving 
themselves all the trouble of thinking, rendering physic 
an art, which may be practised by any one without previous 
study, or present ob-ervation.” So great has been this 
influence upon the pnblic, this infatuation, that in England, 
few persons are now contented, when requiring a plain 
laxative, with the mild vegetable aperients, which we have 
in abundance, nd which produce no constitutional effects, 
but merely open the bowels ; every one mu-t take a portion 
of blue pill, of a metal which does more than is required for 
habitual use ; which weakens the stomach and whole frame, 
and gives a susceptibility of cold. Zimmerman, in his work 
on experience, page 140, notices this tendency in our 
profession to patronUe particular organs, or diseases, 
or remedies. "I know,” says he, "several physicians 
who see only certain diseases : one of these, who 
is a celebrated practitioner, and who has an obstructed 
liver, fancies he discovers a similar complaint in all 
his patients, and it is one particular remedy he con¬ 
stantly prescribes, because he finds it useful to himself; 
another is in love with his theriaca, probably because it con¬ 
fines him to his bed, sometimes for three months ; without 
this same theriaca, if we are to believe him, he would long 
ago have been overcome by bis complaints ; bat with this, 
sajs he, I can master them. I know a third, who is confined 
three or four months every year with the gout, and yet he 
constantly denies that he has anything gouty about him, and 
contends upon all occasions that he never bad so mnch as 
the rheumatism. This physician, and all his patients about 
him, if we are to believe him, are subject to an affection 
of the nervous system, and be employs narcotics upon all 
occasions " The very same things are said in rhyme by our 
own poet Crabbe :— 

“ One to the gout contract* all human pain. 

He views It raging In the frantic brain ; 

Finds it. in fevers, all his effort* mar. 

And sees it lurking In the cold catarrh. 

Bilious by some, by others nervous seen, 

It age the fantastic demons of the spleen ; 

And every symptom of the strange disease. 

With every system of the sage agrees. ” 

Moliere, in bis Malade Tmaginaire, in the person of a 
sham physician, who patnmUei the lungs, ridicules this 
propensit y, and as each sy m ptom is mentioned by the u n happy 
patient, nods his head and says, " Le poumnn 1 justement 
le poumon 1 ” and when the patient has finisher), exclaims 
" Le poumon 1 le ponmon ! 1 ” Some, struck with the fact, 
that inflammation attends so many cases of so many 
diseases, consider every disease an inflammation, as though 
this explained the phenomena of tubercles, cysts, cancer, 
melanosis, dyspepsia, diabetes, and every thing else. 
The occurrence of inflammation in so maty aff ctions, is 
sometimes the disease itself; sometimes an exciting cause, 
sometimes a concomitant, sometimes a part only of the 
disease, sometimes absolutely an effect, and, in a large 
number, it is really absent. No one is more aware than 
myself, of the Importance of looking ont for inflammation in 
every case, and of treating it if found ; but this supposition 
of its universal existence, and of its universa lty as a cause 
of disease, is a mere assumption. My convictions from close, 

I may »av prinfui ob-ervation and reflection, ere the same as 
those of Dr. Andral, in his Tecent work on morbid anatomy ; 
a work which shows full information, and a solid and dis¬ 
passionate judgment, and is the production of a man who 
one day or other, I am sure, will be the first physician » 

The Lancet,] 


fJAN. 4, 1908. 33 



The Diffusion of Medical 

During 1908 The Lancet will enter upon the eighty-sixth 
year of its existence, 1 and while the beginning of every new 
year is naturally made a season for moralising we hope 
that we may claim indulgence for a few words of self- 
congratulation. We are not blind to the need for moralising 
or unaware that during our career we must have made 
errors, but at any rate we can claim that we have never 
faltered in our long endeavour to maintain the dignity of 
medicine and the rights of the medical practitioner. This 
was the object with which The Lancet was founded, and 
the purpose of the founder has been carried out steadily by 
his descendants, the eldest of whom death removed from the 
editorial chair during the year which has just ceased. We 
shall deeply miss his counsel and the lessons of his experi¬ 
ence, but we commence the new year with confidence, for we 
possess the reassuring knowledge that we shall have ex¬ 
tended to us by our professional brethren the same steady 
support that we have received without intermission from the 
inception of the jonrnal. We have come to perceive that 
the work of The Lancet is considered by the medical pro¬ 
fession to be in its nature cooperative, and year by year we 
are confirmed in this flattering view. We can only give to 
our readers the latest medical learning and the most 
practical professional information if we in our turn are 
helped by our readers. Our editorial efforts would have 
no practical result if we did not find among our 
public many who are anxious to communicate through us 
with their professional brethren, thus rendering our pages a 
central bureau for the collection and redistribution of know¬ 
ledge. The responsibilities which are thus placed upon us 
grow no lighter with experience in the attempt to meet 
them. On the contrary the progress of scientific medicine 
brings with it every day fresh problems ; something new 
occurs incessantly which may or may not be significant of 
an important development. Fortunately it does not depend 
upon ourselves alone to decide in all instances what move¬ 
ments make for truth and what are based upon error. Our 
duty is to hear all sides and by submitting them to the 
judgment of our readers to obtain the assistance of their 
criticism before making any pronouncement. We trust also 
that we shall not be found afraid to lead when initiative is 

It seems to us that the feature which has most pro¬ 
minently marked our columns during the past five years is 

1 The first number of The Lancet was issued on Sunday, Oct. 5th. 
1823. Consequently on Oct. 4th. 1907. it completed the eisht.v-fouri h 
year of its ■ xistence, and upon Saturday, Oct. 5'b, 1907, entered upon 
Its eighty-fifth. It is obvious that it ia not possible to make the age of 
The Lancet tally with the calendar year. For purposes of con¬ 
venience it Is found to be most suitable to give upon itie title page of 
each volume of The Lancet the year of existence entered upon in the 
course of that particular calendar year. 

the desire of medical men in all parts of the world to com¬ 
municate with their fellows. It is a truism, which may 
be found in our columns as well as in those of every 
scientific newspaper in every language, that science has 
no geographical limits any more than it has political 
bearings. It is, or should be, as absurd to talk of a French 
school of medicine or a British school of gynaecology as it 
would be to talk of a Home Rule system of dentistry. 
There is scientific medicine, scientific gynaecology, and 
scientific dentistry, and in each case the essential doctrines 
must be dictated by knov.'edge of the truth, by adapta¬ 
tion of accepted principles to circumstances, and by 
examination and sifting of scattered facts so as to form 
them, through collation and comparison, into the founda¬ 
tions of a theory. When, however, we pass from the theory 
to the practice of medicine it is obvious that the environ¬ 
ments of practice will have much to say in respect to the 
measures employed as well as to the conditions observed. 
The climate, the health and the manners of the people, 
the extent to which they are as a whole liberally educated 
or the reverse, the industries on which the population 
is employed, the ease or difficulty with which money is 
gained at those industries, and all the other circumstances 
which make up the sociology of a race will, of course, 
determine the classes of disease and of injury which are 
likely to be prevalent, as well as the facility or difficulty 
with which remedial actions may be taken. But the 
methods of diagnosis must be universal and those of treat¬ 
ment must be based upon identical and ascertained truths. 
When the world was small and the interchange of ideas 
between distant nations was restricted owing to the 
rigorous limitations of the means of transport, althongh 
the scientific practice of medicine was bound to have the 
game foundations all the world over, the conditions were 
such that in different places different procedures were 
pursued, for opportunities were wanting by which schools 
of thought could compare and test their theories and their 
results. But of recent years the association between 
the peoples of the earth has become vastly more inti¬ 
mate, and nothing so marks the progress of civilisation as 
this opening up of rapid channels of intercommuni¬ 
cation. Great Britain and her colonies have gained a 
knowledge of each other during the short period which 
the twentieth century has yet run which is surprisingly 
large and general, considering that in the Victorian era 
most of those at home knew nothing of the life of our 
dependencies, while oar colonial brethren knew but little 
more of us This is a situation which has recently undergone 
satisfactory change. The United States of America in 
circumstances which have not been entirely cheerful for them 
have also improved their acquaintance with the rest of the 
world; they have learned something of the burdens which 
must be taken up by great civilising powers. On the con¬ 
tinent the commercial industry of Germany has compelled 
all European powers to consider their fiscal position, with 
tbe result that there is a great increase on all sides of 
national knowledge of the trade-manners and trade- 
customs of foreign neighbours. Russia and Japan under¬ 
stand each other far better than they did before their 
terrific struggle and have learned lessons from each 
other which neither can ever forget. In a happier 

34 The Lancet,] 


[Jan. 4,1908. 

way the personal influence of our King has been used to 
secure a better comprehension of English aims by the world 
at large. The outcome of all this must be the placing of 
our profession upon a securer basis, for as the different 
nations rise in the scale of civilisation and obtain a more 
just acquaintance with their neighbours they must come to 
perceive how universal are the laws of scientific medicine. 
They find themselves confronted with the same problems, 
sanitary or pathological, as their friends abroad, and they 
learn to appreciate the labours of medical men by applying 
to their own use the fruit of these labours. 

We have endeavoured, particularly during the last three or 
four years, to illustrate the truth of this movement by placing 
before our readers regular correspondence from all parts of 
the world. The mere sire of such a programme makes it in¬ 
evitable that the communications should be brief, but we are 
happy to know that they prove of considerable service to 
our readers, while it is interesting to observe how the same 
scientific and professional difficulties present themselves 
in every quarter. We hope and believe that in the newer 
countries scientific medicine will be able to develop faster 
than it has done in Europe in bygone days, for these 
countries will be unhampered by traditions having their 
origin in restricted knowledge and sociological mis¬ 
conception. In particular their authorities and important 
persons, both medical and lay, are able to work at 
once from a position to which we in this country 
are now only beginning to attain. They follow 
the reasons for scientific proceedings in a way which 
they could not possibly have done had it not been 
for the past labours of the medical profession, and 
the medical profession will be invited to call upon 
the assistance of laymen for the advancement of scientific 
medicine, a fact which is of great importance now 
that medicine touches the borders or passes over into the 
territory of so many other sciences. Great advances in 
medical knowledge are inevitably coming of the growing 
recognition of medicine by the world as a science com¬ 
pounded of sciences; while the disappearance from the 
popular mind of the conception of the practitioner as a sort 
of magician is being replaced in every direction by a 
more reasonable estimate of his services. We know 
—none better—that the practitioner has many draw¬ 
backs in his hard and anxious life, and we grieve to 
think that many of these could easily be set right in our 
own country by a more complete understanding of profes¬ 
sional aims and responsibilities than yet exists, but despite 
this the story of medicine is one of progress. The public 
sympathy with medicine increases, and it will continue to do 
so in proportion to the advancement of education and of 
that wide spread of sound medical doctrine to which we are 
proud to be able in some measure to contribute. 

Heroes of Thought. 

“ Hellenists, professors of Roman law, and enthusiasts of 
Romantic or Christian mediaevalism are not to be easily con¬ 
vinced that an intelligible stream of progress can be shown 
in the long, brokeD, stormy course of evolution from Solon 
and Thales to the nineteenth century of Cavour and 
Darwin. Rut a true philosophy of history can trace a real 

and consistent sequence.” Thus writes Mr. Frederic 

Harrison in an introduction to a volume of “ Essays and 
Addresses” by the late John Henry Bridges. 1 The first 
half of this book is devoted to essays in Positivist 
doctrine, of which, as is well known, Dr. Bridges 
was one of the most distinguished exponents in this 
country. One of these essays, entitled “The Philo¬ 

sophy of History,” might well serve as a text for 
the whole book, for in it an attempt is made to 

sustain one of the central tenets of the Positivist school— 
that of the principle of historical growth or of continuity 
in progress. 

In tracing the oonrse of Western civilisation during 
the 25 centuries since its dawn in the times of the 

great Greek thinkers, it is claimed that the state of the 
speculative faculties of mankind is the prime agent in social 
advance and progress, and further that the social change 
of each successive period resulted not from the praotical life 
of that period but from the previous stato of belief and 
thought, and that therefore the order of human progression 
depends mainly, or at any rate largely, upon the order of 
progression in the intellectual convictions of mankind. When 
we remember the importance assigned by Comte to mathe¬ 
matics as the basis of systematic thought, it is not surprising 
to find that Dr. Bridges maintained that the most original 
achievement of Greece was neither her poetry nor her 
metaphysical philosophy but her separation of mathematics, 
the humblest and yet the most fundamental of the abstract 
sciences, from the confused collection or inchoate maee of 
empirical knowledge which mankind bad previonsly accumu¬ 
lated. Dr. Bridges complained that history as commonly 
taught does not include the history of science and that even 
now the sociological importance of its great disooveries ie 
only just beginning to be recognised. In illustration of the law 
of continuity he shows bow tbe discoveries in geometry and 
mathematical astronomy made by tbe Greeks were adopted 
and extended by the Arab schools of Bagdad and Oordova, 
to be continued by the Western thinkers of the thirteenth 
century, men such as Grosseteste and Roger Bacon, ho 
bis opinion there was. no dark age, even in the apparent 
retrogression of mediteval Europe before the Renaissance, 
for he maintained that whereas in ancient Greece there wa» 
a great development of tbe intellectual aspects of human 
faculties and in ancient Rome great practical activity in 
political and warlike spheres, tbe third or spiritual part of 
man's threefold nature was but little advanced till these so- 
called dark ages. In these times learning began to extend 
from the favoured few to the many through the medium of 
the monastic teachers, while the great social revolution 
from servile to free labour began. Dr. Bridges illustrated 
his views in some commemorative addresses which form the 
second part of this book. These lectures were delivered on 
certain days in the “Positivist Calendar of Great Men.” 
Among these, he treats of Thales, Roger Bacon, and 
Harvey as heroes of thought; Dante, Calderon, 
Corneille, and Diderot as heroes of literature. 

The account given of the importance to mankind of the 

1 Essays and Addresses, by tbe late John Ilenry Bridges, M.B. r 
F.R.C.P.*. sometime Fellow of Oriel College, Oxford; late Medical 
Metropolitan Inspector to tbe Local Government Board. With an 
introduction by Frederic Harrison. London; Chapman and Hall, 
Limited. 1907. Pp. 307. Price 12s. 6d. net. 

The Lancet,] 


[Jan. 4,1908. 35 

elementary mathematical abstractions of Thales and the 
ether Greek geometers is exceedingly interesting. Starting 
from the practical problems involved in land measurement 
they laid the foundations of physicB and astronomy and evolved 
certain fundamental laws—indeed, the tirst laws of nature 
to be grasped by man. It is hard for us now to conceive 
without oareful thought of the great advance made in the 
two apparently simple abstractions of the line and the angle, 
and yet they form the basis of all measurement and without 
them no calculation or accurate mensuration would be 
possible. The further conception of the triangle, the 
simplest possible figure, was the one in connexion with which 
Thales made his greatest discoveries, among whioh the law 
that the three angles of any triangle were equal together to 
two right angles is one of the most familiar. Another great 
law discovered by this master mind was that of the similarity 
of two figures of unequal sides and equal angles by means of 
which he taught the Egyptians how to measure the height 
of their pyramids. This was done by measuring the length 
of the shadow cast when the sun was halfway between the 
zenith and the horizon, since at that moment the shadow 
of a stick placed upright in the ground was found to be equal 
to the length of the stick itself. Without these great 
fundamental conceptions and the laws deduced therefrom 
there could have been no astronomy, no mechanics, no 
navigation, and no true conception of order which is in turn 
the basis to which science endeavours to reduce the complex 
problems met with in biological and sociological studies. 

It is a long step from Thales to Roger Bacon, from the 
ancient to the medimval, but Bacon stands out from the 
schoolmen as a great philosopher and a practical man of 
science, and Dr. Bridces’s long study and special knowledge 
of the great Franciscan friar are here summarised in a most 
illuminating essay. The influence upon his career of his 
early association with Grosseteste at Oxford, who probably 
directed his attention towards science, the importance of 
his introduction to the Arabian adaptations of Greek dis¬ 
coveries through the agency of Michael Scott, and the 
effect of his whole-hearted attachment to the Franciscan 
order are all clearly indicated. It is only in recent times 
that we have realised what we owe to Arabian philosophers 
and men of science who preserved what the Greeks had 
discovered in arithmetic, geometry, astronomy, natural 
history, and hnman anatomy. Moreover, the Arabian and 
Moorish schools in many instances made great advances, 
since their instruments of observation were more accurate 
than those of the Greeks. They laid the foundations of 
algebra and of optics. They adopted, if they did not dis¬ 
cover, the decimal system, and they promoted the study of 
trigonometry, while their advances in chemistry and in 
medical sciences were truly remarkable. Roger Bacon was 
one of the first to render this great store of Eastern know¬ 
ledge accessible to Western thinkers, his object being to 
show the West superior to the East and to advance learning 
through religious agencies with a view to the reform of 
education and the promotion of knowledge. His “Opus 
Majus ” is one of the most remarkable surveys of knowledge 
extant and shows him to be greatly in advance of 
his contemporaries; indeed, he has been desoribed as 
a man born some three centuries before his time. He 
devotee the earlier sections of his work to the four great 

obstacles to wisdom—namely, undue deference to authority, 
custom, popular prejudice, and unwillingness to confess 
ignorance. His instruments for advancing the studies of 
Western Europe were philology, mathematics, and experi¬ 
mental research, and to these the second, third, fourth, and 
fifth sections of the “ Opus Majus ” were devoted. To mathe¬ 
matics he attached the greatest possible importance, de¬ 
scribing it as the key and entrance-gate of science. His 
application of mathematics to geography led him to a careful 
study of geography and to the compilation of a treatise 
thereon. He pointed out the necessity for a reform of the 
Julian Calendar which was delayed for three centuries after 
his death before it was carried out. The seventh section of 
the “Opus Majus,” of whioh only part is preserved, dealt 
with practical reason and ethics and is the crowning of his 
work. This essay of Dr. Bridges is the most interesting 
short study that we have read on this great philosopher, and 
as Mr. Harrison writes in bis introduction, makes one 
wonder “if we are right in putting Francis Bacon on a 
pedestal higher than that occupied by Roger." 

The third of these commemorative addresses, entitled 
“Harvey and his Successors,” was delivered as the Harveian 
Oration before the Royal College of Physicians of London, in 
1892. Here again the importance of mathematics in rela¬ 
tion to science is emphasised. Harvey was born at the 
time when England gave birth to her greatest men in 
literature, philosophy, and science, to quote Dr. Bridges, 
“the greatest period of English history.” At Padua he 
studied under F abricius and may well have come under the 
influence of Galileo, who was then attracting students from 
all partB to Padua, and although there is no record of personal 
acquaintance between the two men there can be little 
doubt that the influence of Galileo's physical advances 
was felt by Harvey, who, as Dr. Bridges wrote, “came 
back from Padua with the sense that Nature was not merely 
to be observed but measured.” Harvey’s great work was the 
application of scientific methods to the study of living 
organisms, and by this means the complex aichemistic or 
humoral explanations of vital processes were at once dis¬ 
proved. Dr. Bridges traced in this address the influence of 
Harvey’s work upon his contemporaries and successors. 
The appreciation of his work by Descartes and the com¬ 
bined influence of his discoveries and the Cartesian philo¬ 
sophy in leading to the foundation of scientific medicine are 
discussed. The origin of the iatro-matbematical or iatro- 
physical and the chemiatric schools is traced and the subse¬ 
quent foundation of an animist school by Stahl at the end 
of the seventeenth century is outlined. It was not, however, 
nntil the eighteenth oentury that biology became recognised 
as a distinct science with special methods, but the great 
discoveries of Harvey were the direct outcome of the 
mathematical and physical discoveries made in his time. 
It has been said that science is measurement and Dr. 
Bridges’s interesting addresses afford a striking illustra¬ 
tion in support of the trite generalisation. The three 
great men whom he has studied were all heroes of thought 
who in face of obstacles applied accurate methods to the 
practical study of the problems which they investigated. It 
is highly instructive to follow the work of three such 
striking philosophers as the Greek geometer, the medimval 
physicist, and the first scientific biologist. We oan 

36 The Lancet,] 


[Jan. 4,1908. 

cordially commend this interesting collection of thoughtful 
essays to onr readers as a stimulating and suggestive study. 

The Coordination of Medical 

To consider the beginnings of medical study at the 
beginning of the year seems to us appropriate, and we 
therefore publish in this issue two interesting contributions 
on the study of anatomy and embryology contributed by 
well-known teachers in different schools, feeling sure that 
they will afford abundant food for thought to the man who 
is at all concerned about the future of medical education 
in this country. Dr. Arthur Keith in his address to the 
students of the London Hospital very clearly setB forth a 
convincing case against the fashion of entirely divorcing 
the study of anatomy from that of physiology with the 
result that the average student starts on his profes¬ 
sional career with his knowledge of the structure and 
the function of the human body stored away in two 
watertight compartments in his mind. It is a useful cor¬ 
rective to over sanguine ideas as to the complete efficiency 
of the present state of medical education to be told by 
Dr. Keith how recently we have fallen away from 
higher standards in our systematic teaching of anatomy. 
“Up to the end of the eighteenth century,” he says, 
“ there was a strong school of British anatomists who 
regarded dissecting as a means for obtaining not a 
description but an understanding of the human body ; ” and 
surely this was the ideal of the great anatomists of all past 
ages as witness Herophilus and Galen amongst the 
ancients, Eustachius, Fallopius, Steno, and Sylvius 
in succeeding centuries after the mediaeval revival of the 
neglected science, and, greatest of all, William Harvey 
and the two Hunters at whose handiwork of dissection 
we may still look with our own eyes. What would John 
Hunter have thought, what would he have said, could 
he have looked forward to see his methods of thinking and 
teaching entirely superseded by the brilliant categorical and 
purely descriptive anatomy which the schools of Paris even 
in Hunter's lifetime were setting up? 

The British student sought Paris a hundred years ago 
because the difficulty of obtaining subjects for dissection 
hampered his teachers at home and not because he had any 
fault to find with their teaching. But Dr. Keith is right in 
pointing out that the method of anatomical instruction thus 
started soon became established in England as a custom, and 
even the old concession made by authors to the cause of 
the solidarity of medicine in writing on “Anatomy, 
Descriptive and Surgical,” is lacking in many more modern 
treatises, excellent indeed after their sort, but composed 
of des ;riptive anatomy pure and simple. There is no doubt 
that this divorce of structure from function is an 
error. Save for the very rare student with an 
inherent genius for one or other of these studies the 
sole aim of teaching a medical student anatomy and phy¬ 
siology is that he may become a scientific physician or a 
rationil surgeon who has built his professional house on the 
solid rock of well-ascertained fact. What is required by 
medical students is instruction in theory and detail alike 
of the kind which will make the pathological processes 

which they are afterwards to study comprehensible 
to them. Teachers are wanted who can clothe the 
dry bones of their lectures on anatomy with the living 
tissues of physiology and morphology and render them yet 
more vital to the medical student by pressing into service 
illustrations from medicine and surgery, so that the warp 
of structure and the woof of funotion may be woven into 
a stout garment of knowledge to clothe the student’s mind 
in the place of the patchwoik cloak in which it must now too 
often go forth, shivering on a stormy journey. Instances 
arise of the need of teaching of this sort in the con¬ 
sideration of every system in the body, for the circulation, 
the respiration, the digestion, and the functions of the brain 
can be much better grasped by the simultaneous teaching 
of their anatomy and physiology. The physiological teacher 
is occasionally obliged to sketch the rough outline of 
the coarse anatomy of the subjects with which he deals, for 
often, as in dealing with the brain, he must do so 
to make himself understood at all, and he also either 
in propria persona or through an assistant in histology 
devotes much care to teaching the microscopical structure 
of the various tissues ; but it is to a much fuller extent that 
we would have the physiologist invoke his anatomy ; might 
not he, for instance, occasionally direct more attention to 
the ordinary functions of muscles illustrated from gToss 
anatomy instead of spending nearly all the time that be can 
give to them in the demonstration of their chemical and 
electrical niceties ? Still more often does the anatomical 
teacher appear to ns to miss the true reasons of the lessons 
which he is giving by avoiding the very mention of any¬ 
thing that savours of physiology, referring such subjects 
to the other department of the medical school. We 
would even suggest that examiners might rest content 
with a little less minute knowledge of ultimate divisions of 
small nerves and arteries and markings on bones when 
the time saved might be employed by students in gain¬ 
ing a good working idea of the human machine. How 
many men on first entering on clinical work can look at 
a patient and form a clear mental picture of his organs 
as they lie inside him and at the same time even faintly 
realise the ceaseless and multiple activities of their vital 
functions 1 The average student sitting for an examination in 
surgery knows the anatomy of hernia thoroughly, for he was 
brought up on it, but there are many more anatomical 
points the vital surgical importance of which might with 
equal advantage be impressed on the student of anatomy 
when he first learns it; whilst the physiological teacher 
could take many more illustrations than is his wont from 
the field of medicine. And in neither case need the student 
be taken into the wards; the pathological deviation from 
the normal could be explained by consideration of the 

Professor Peter Thompson’s lecture on the Study of 
Embryology bears testimony to the truth of the contention 
that medical studies are not well coordinated despite the 
ceaseless care that has been exercised in arranging the 
numerous systems. Embryology is a study the importance 
of which has been appreciated Bince the days of William 
Harvey at least; a great deal is now known about 
it which might profitably be the common knowledge 
tf every medical student, and yet how often doee it 


fall between the two stools of anatom; and physio¬ 
logy, each granting it bat half-hearted support and 
relegating it to one or two scrambled lectures which are 
neither complete in themselves nor complementary to each 
other. The teaching of the development of the foetus in 
utero is indeed often largely handed on to a lecturer in 
midwifery who has only just enough hours at his disposal to 
summarise the bare facts of obstetrics and might reasonably 
suppose his bearers to come equipped with the physiology of 
foetal development and even of the normal processes of 
birth so far as they fall under the headings of anatomical 
and physiological functions. The present medical curriculum 
is allowed on all hands to require lightening. The average 
student has to learn a large quantity of things that will 
be of no use to him and has to spend an extravagant 
amount of time in acquiring the knowledge. One method 
at least of economising time and labour would be to teach 
anatomy and physiology for the compulsory courses far 
more directly in relation to the professional career. 


"Ne quid 

Sugar is often given a bad name from a physiological 
standpoint but in many instances it is questionable whether 
it is deserved. It seems inconceivable that the bountifulness 
with which the world is supplied with sugar should mean 
anything else than that it is designed for human food. 
Sugar is one of the most powerful foods which we possess as 
it is the cheapest, or, at any rate, one of the cheapest. 
In muscular labour no food appears to be able to 
give the same powers of endurance as sugar; and com¬ 
parative practical experiments have shown without the least 
doubt that the hard physical worker, the athlete, or the 
soldier on the march is much more equal to the physical 
strain placed upon him when he has had included in his diet 
a liberal allowance of sugar than when sugar is denied to 
him. Trophies, prizes, and cups have undoubtedly been won on 
a diet in which sugar was intentionally a notable constituent. 
It has even been said that sugar may decide a battle and 
that jam after all is something more than a mere sweetmeat 
to the soldier. The fact that sugar is a powerful “muscle 
food ” accounts probably for the disfavour into which it falls, 
for a comparatively small quantity amounts to an excess, and 
excess is always inimical to the easy working of the digestive 
processes. A strong solution of sugar is irritating to the 
tissues, will set up superficial inflammation, and may produce 
a form of eczema. It is well known that an excessive diet of 
sugar irritates the mucous membrane of the stomach and 
encourages the production of mucus and of a highly acid 
gastric juice. The ingestion of much sugar spoils the 
appetite. Children who have been tempted to over-indulge 
in “lollipops” between regular eating times do not want 
their ordinary meal. The schoolboy spoils his dinner by 
eating too many sweet things before that meal. An over- 
indulgence in sweet liqueurs, in sweet ices, and in 
“ crystallised ” fruits after dinner retards the digestion of 
the meal. Sugar satiates ; it is a concentrated food. Where 
sugar does harm, therefore, it is invariably due to excess. 
Taken in Bmall quantities and distributed over the daily 
food intakes sugar contributes most usefully in health to the 
supply of energy required by the body. In certain diseases, 
of course, the presence of sugar in the diet is plainly 

undesirable. Generally speaking, however, there is a pre¬ 
judice against sugar which is not justified by physiological 
reasoning—at all events, when it is eaten in moderation ; 
and it is a curious fact that the man who practically abstains 
from sugar, or reduces his diet to one almost free from carbo¬ 
hydrates in favour of protein foods such as meat, often shows 
feeble muscular energy and an indifferent capacity for 
physical endurance. _ 


The question of remuneration for private work performed 
by Indian medical officers in their spare time has again risen 
to the surface, the motive power that caused the resurrection 
being, as usual, jealousy. In a long and bitter letter to the 
Pioneer, signed “Pro Bono Publico,” the writer either begs 
the question or else relies upon assertion. 11 1 know of many 
cases," he says, but instances none, “in which Indian chiefs 
have appealed to their political agents against the fees which 
the agency surgeons were charging, and everyone with any 
knowledge of the eutycct must be aware how the present 
legislation restricting fees has been brought about chiefly 
through the enormous fees which certain members of 
the I.M.S. charged to Indian chiefs.” The italics are 
ours. When an anonymous writer makes unsupported 
statements they have no importance. We need not 
accordingly occupy more space with this portion of 
the attack. Proceeding with his diatribe, “ Pro Bono 
Publico ” asserts that “ the ordinary Indian doctor has no 
more knowledge, except of special tropical diseases, than the 
usual English country practitioner who charges 7». 6 d. or 
10s. per visit, and in respect of his knowledge of women's 
diseases he is generally partly inferior, yet he demands the 
fees of a first-class London specialist (who only charges a 
guinea per visit after the first visit) in addition to drawing 
his Government salary. Safe in the knowledge that he hag 
his Government pay and that he is entirely free from com¬ 
petition, the Indian civil Burgeon has no incentive to keep up 
his professional knowledge, and the medical fossils which 
could be dug out of many of the smaller stations in India 
would fairly startle their brethren at home.” The only use 
served by vituperation of this calibre consists in the exposure 
of the writer’s animus. That the members of the Indian 
Medical Service are second to none either in professional 
knowledge or in general intelligence is shown by the marks 
and places which they obtain in competitive examinations. 
There is not a session of the London School of Tropical Medi¬ 
cine where the class fails to include several Indian medical 
officers, ranking from colonel to lieutenant, the time thus 
devoted being deducted from private leave. The animus 
alluded to above assumes a very unpleasant form in the 
remarks which "Pro Bono Pablico ” sees fit to make regard¬ 
ing the losses recently sustained by the Indian Medical 
Service through devotion to duty. “ How many men in all 
other branches of the Indian services die at their posts,” 
he exclaims, “and lose their lives in the execution of 
their duty! Why should such deaths constitute a 
special claim in the case of the I.M.S. and not in 
the case of the other services?” To what is “Pro 
Bono Pablico” referring? He further asserts that the 
right to accept private practice which is enjoyed by officers 
of the Indian Medical Service is due to long-established 
custom, and graciously adds that it may be admitted as 
“a concession which is granted to no other profession.” 
It may have surprised him to learn that the right in 
question was granted by Act of Parliament which has never 
been repealed (13 George III., c. 63). In its editorial 
columns the Pioneer fully exposes the inexactitudes with 
which the letter of its correspondent abounds. “In the 
case of the law,” says the Pioneer, “which approximates 

38 Thu Lancet,] 


[Jan. 4, 1908. 

most nearly to medicine, the principle of private practice is 
fully admitted. If the State had to maintain a corps of 
whole time Government advocates and public prosecutors all 
over the country it would either have to pay a prohibitive 
sum or put up with very indifferent agents.” Precisely so : 
the two cases are accurately on all fours; and moreover no 
Government, save for income-tax purposes, would venture to 
order its legal servants to furnish the details of their private 
incomes. Iu the ca.-e of medical cilicers the Government 
does make this inquisitorial demand, and, strange to say, 
Indian Engineering , usually so enlightened, contends that 
it is justified in so doing. Engineers in India are not allowed 
to engage in private practice but that is no reason 
for denying a reasonable privilege to another body of 
men. Our contemporary says that when it comes to a 
civil surgeon getting a lakh or two for any service the 
Government is wise to interfere. Perhaps so, but do such 
cases occur in real life ? We do not believe it. It is but 
another instance of question-begging. We can assure the 
writer of the article entitled “ Professional Fees ” in Indian 
Engineering, dated Nov. 13th, that the virtual extortion of 
fabulous sums from rajahs (or from anybody else for that 
matter) by the Indian Medical Service does not occur, and 
the moral odium cast on an honourable service by such loose 
accusations is bitterly resented. 


THERE Is little doubt that the present financial stress in 
America has been coincident with a large number of suicides 
and it is of more than passing interest to consider whether 
the one is a natural accompaniment of the other and whether 
self-destruction must be considered as a common corollary to 
severe monetary losses. It must be borne in mind that the 
successful man of business is commonly a highly neurotic 
subject—in truth, he frequently owes his very success to his 
keen sensibility and his deftness in foreseeing the trend 
of coming events. Now men are prone to forget, or 
maybe they are ignorant of the fact, that the type of nervous 
system whioh endows them with so many advantages is a 
highly unstable mechanism and renders them more liable 
to sudden fatigue or mental aberration than the less sensitive 
system of their more lethargic neighbour. Sudden stresses are 
more likely to lead to impulsive acts than are adverse circum¬ 
stances of gradual onset. Periods of monetary stringency 
caused by trade depression have not uncommonly been noted 
as cycles during which the incidence of insanity has fallen. 
Times of difficulty undoubtedly weigh heavily on some indi¬ 
viduals but given a few weeks the man soon gets used to his 
altered circumstances and hardships alone seldom produce 
mental disorder. But this is not so with sudden calamity. 
The millionaire of yesterday who is faced with ruin 
to-day has received a severe mental shock, and a profound 
emotional disturbance such as this paralyses judgment. Now 
uncontrolled emotion is a common precursor of rash acts. 
The once prosperous man who is suddenly confronted with 
bankruptcy is liable to lose the very attribute by which he 
attained bis success ; judgment is replaced by impulse and 
he not uncommonly plunges deeper and deeper into the 
morass and his affairs become increasingly involved ; nights 
are spent in vain attempts to disentangle himself from the 
impending disaster and he has no proper time for meals or 
sleep; he soon becomes physically weakened and tills ac¬ 
centuates his mental distraction, symptoms of fatigue appear, 
and the mind becomes confused and in consequence irrational 
acts may be performed. It must further be borne in mind 
that suicidal acts are more common in the earlier periods 
of a mental illness than during the later phases, and this fact 
alone accounts for an appreciable number of deaths of 
persons who succeed in destroying themselves before their 

disorder is recognised. So far we have only referred to the 
class of financier who is not necessarily a speculator but 
frequently a man whose business is sound and legitimate, 
notwithstanding the fact that he is dealing in large sums of 
money. But there is another type of person whom we may 
designate as a common gambler, for his vocation is 
speculating with money that he does not possess, and his 
success or ruin is more dependent upon the caprice of 
fortune. Now gambling appeals very forcibly to a certain 
degenerate class or ne'er-do-wells. The life of such a person 
is a lottery ; he plays to win but if he loses he has already 
thought out the remedy and suicide to him will appear to- 
be little more than a move in the game. We do Dot 
believe that there are many such men, but a certain 
number do exist and their self-destruction goes to 
swell the total number of tragic deaths which are 
inseparable from every great financial crisis. Suicide may 
be the termination of a life spent in gambling or it may 
follow the downfall of the man who, either from pride or 
lack of moral courage, is unable to face comparative poverty 
or to see his family, who were once surrounded with luxury, 
driven to earn their living. In this way a sudden financial 
collapse must be held responsible for the wave of suicide 
which so commonly follows in its train, but the majority of 
deaths by self-destruction are brought about by far more 
complicated stresses which undermine both the physical and 
the mental health of the individual, and the culminating act, 
is only done when the mind of the distracted person becomes 
so confused that impulse replaces judgment and voluntary 


By this Act, which came into force on Jan. 1st, a statutory 
maximum limit of 16 per cent, of water is imposed in the oase 
of all butters, with the exception of “ milk-blended butter,” 
which is to be allowed to have as much as 24 per cent. Be¬ 
long as it is sold by a name which is approved by the- 
Board of Agriculture and one which is not “ suggestive of 
butter or anything connected with the dairy interest. ” The 
names under which margarine is sold are to be subject to the 
same restrictions. It is, perhaps, open to question whether 
the new statutory limits for moisture in butter and margarine 
will very much benefit the consumer ; a large proportion of 
both articles has certainly contained considerably less than 
16 per cent, in the past. The principal advantage of the 
Act, however, is the substitution of a system of control! 
at the port of importation (through the Customs autho¬ 
rities and the Government laboratory) and in this 
country at the place of manufacture for the present 
methods which are based almost wholly on analysis 
of purchased samples. These methods have constantly 
broken down in cases where small quantities of foreign oils 
and fats have been “blended” or worked in with natural 
butter with considerable profit to the blender. Places where 
butter is blended “by way of trade” will now have to be 
registered and no foreign fats are to be kept on such 
premises. Wholesale “blending” of butter and margarine 
making are not to be carried out on the same premises, 
although exceptions may be made for existing factories. 
Another considerable advantage of the Act is that it empowers 
the Local Government Board to schedule and to regulate 
the use of preservatives in butter, milk-blended butter, and 
margarine, and it may be hoped that this will speedily be 
done. A circular has now been issued by the Board of 
Agriculture as to the action which looal authorities are 
recommended to take under the new Act. Apparently 
the principal duty required of them is to see that 
butter-blending, milk-blending, and margarine-making 
premises are all duly registered and to report to the 
Board of Agriculture cases where in course of ordinary 

The Lancet,] 


[Jan. 4, 1908. 39- 

sampling it is fonnd that the permitted limits of moisture 
have been exceeded. It maybe gathered from the circular 
that routine inspection of the registered factories will be 
made by officers of the Board of Agriculture. The circular 
points out, however, that under Section 2 of the new Act 
local authorities have powers to authorise any officer who is 
authorised to procure samples under the Sale of Food and 
Drugs Acts to enter any registered butter factory for the 
purpose of inspection of processes and taking samples. These 
powers may be found useful by medical officers of health in 
cases where there is reason to question the wboleBomeness of 
the methods of manufacture carried on in the premises 
registered with their authorities ; and it would probably be 
advantageous to all medical officers of health in the districts 
covered to arrange to be supplied with information as to the 
registered premises and with the necessary authorisation to 
inspect any of them. 


IN the British Journal of Children's Diseases for November, 
1907, Mr. H. S. Clogg has reported the following case of pnen. 
mococcic infection of serous membranes which presents 
several points of interest. A girl, aged four and a half years, 
was admitted into hospital on Sept. 2nd, 1907. She became ill 
on July 28tb with doable pneumonia. The crisis occurred on 
the fifth day but though the temperature remained normal, 
or nearly so, improvement was not satisfactory. The dulness 
at the bases of the lungs persisted and moist sounds 
were heard all over the chest, except at the right 
apex where the breathing was markedly blowing. 
Towards the end of the second week the abdomen was 
somewhat swollen. The ohild lost flesh, the pulmonary 
signs did not clear up, the breathing became gradually 
more embarrassed, and the abdomen continued to swell, but 
the temperature remained practically normal. On admission 
she was thin and pale, there were considerable dyspnoea and 
cyanosis of the lips, the temperature was 100 • 2° F., and the 
pulse was 140. The apex beat of the heart could be neither 
seen nor felt. The heart sounds were best heard over the 
left edge of the sternum, about the level of the fourth costal 
cartilage. The breath sounds were distinct anteriorly as low 
as the third rib; below this they were faint and there wa 8 
dnlness to percussion. On the left side was marked 
dnlness to percussion and the breath sounds were very 
faint. Posteriorly as high as the mid-scapular region 
there was dulness over both lungs, vocal fremitus was 
absent, and the breath sonnds were faint. The abdomen 
was much distended with fluid. Both sides of the chest 
were explored. The result on the right side was negative ; 
from the left chest pus was withdrawn. Two hours later 
under chloroform a needle was again inserted in the left 
seventh intercostal space and a fen drops of pus were with¬ 
drawn ; a rib was resected and the parietal pleura was 
incised. The latter was much thickened. The surface 
of the lung beneath showed a small area of lymph. By 
inserting a finger into the pleural cavity and gently sweeping 
it in all directions pus was found. Evidently when the chest 
was explored a small abscess had been entered and evacuated. 
The exposed lung appeared to be pneumonic. A small gauze 
drain was inserted and the greater part of the wound was 
sewn up. The child stood the operation badly ; she became 
collapsed, the cyanosis increased, and the pulse was 
hardly peroeptible. Under the belief that the dyspnoei 
was partly due to the pressure of the abdominal fluid 
on the lungs, paracentesis abdominis was performed 
about 24 hours after the operation and 13 ounces of 
pus were withdrawn. The respiration improved and 
a few hours later the abdomen was opened in the middle 
line below the umbilicus and three or four pints of very 

thick, yellowish green pns were removed. Further incisions 
were made in each loin and drainage-tabes were inserted in 
each wound. Drainage of the abdomen was satisfactory 
but the cyanosis persisted and the dyspnrea was un¬ 
diminished. The temperature did not range above 99'6°. 
Two days later death occurred suddenly. At the necropsy 
the brain and meninges were found to be normal. The peri¬ 
cardium was distended with 16 ounces of thick greenish 
pus. Both the parietal and visceral layers were thickened 
and covered with thick layers of lymph. There was 
generalised double pleurisy with numerous recent adhesions. 
In the left pleural cavity at the level of the ninth rib 
were about two drachms of pus inclosed by recent 
adhesions. On tbe right side, about the level of the seventh 
rib, in the posterior scapular line was a similar col¬ 
lection. The upper lobe of the right lung showed some 
redema, the middle and lower lobes considerable cedema. 
The upper lobe of the left lung showed some oedema ; the 
lower lobe was very congested. The intestines were covered 
by a layer of lymph and bound together by recent adhesions 
which here and there formed pockets inclosing pns. The 
intestines showed inflammatory changes. The pelvic peri¬ 
toneum was severely affected but the pelvic organs were 
normal. Cultures from the pleurae, pericardium, and peri¬ 
toneum showed the pneumococcus in pure culture. The case 
seemed to have been an example of primary pneumonia with 
secondary infection of the pleurae, pericardium, and peri¬ 
toneum. There was no evidence that the abdomen had been 
infected by extension from the pleura or from the ailmentary 
canal. The pericarditis was entirely overlooked. On admis¬ 
sion the dyspnoea was thonght to be due to an empyema, a» 
pns had been found in the chest, but when exploration showed 
only a few drops of pus the dy6pDoca was thought to be due 
to the pulmonary disease and possibly to be increased by the 
pressure of the abdominal fluid. 


In tbe medical section of the recently published volume 
of Prison Statistics (1906) for England and Wales some 
pertinent comments are made as to the alleged onset of an 
attack of delirium tremens as the result of a heavy drinker 
being suddenly and completely deprived of alcoholic drink. 
212,000 persons were incarcerated faring last year in local 
prisons and of these 132 died ; three of this number had 
“ delirium tremens ” certified as a cause of, or as a condition 
at, death. 63,000 persons, exactly one-third of whom were 
females, were sent to prison for drunkenness; very many 
more prisoners were of course notorious drinkers, although 
they had committed other definite offences. 246 cases o* 
delirium tremens were recorded, exactly one-quarter of this 
number being females ; of these, four men and one woman 
were certified as insane and sent to asylums, 159 men and 
59 women had recovered at the expiration of their sentences, 
and 16 men and six women were discharged at the end of 
their term. Another interesting fact is that epileptiform 
convulsions are stated rarely to be seen among alcoholic 
prisoners. There appears therefore to be little support for 
the old theory and practice of giving a man verging on 
delirium tremens “a hair of the dog that bit him.” 


In the Repertoire de 1‘harmaeie M Abal has dealt with the 
physiological action of collinsonia Canadensis. This plant 
contains a glucoside of the saponin type and a resin. The 
alcoholic extract of the root when given to animals in small 
doses produces hyper-excitability. In large doses this is 
followed by depression, leading to paralysis of central origin, 
with circulatory disturbances and irritation of the glandular 

40 The Lancet,] 


[Jan. 4, 1906. 

system. The glacoeide in mild doses eats as a feeble cardiac 
tonic, and in larger doses the irritant effects preponderate, 
giving rise in cold-blooded animals to asystole alternating 
with an increase of systolic energy. In warm-blooded 
animals there is a rapid lowering of arterial pressnre with 
increased force of the heart beat. Though the resin acts less 
energetically it augments the action of the heart. It excites 
the secretions of the gastro-intestinal tract and provokes 
marked diuresis, probably owing to its action on the circula¬ 
tion as well as on the renal epithelium. The diuretic action 
is accompanied by an increased output of all the urinary 
constituents. The drug is chiefly used as a diuretic. 


New Zealand has through the demise of Sir James Hector 
M.D. Edin., F.R S., K.C.M G., the director of the Geologica 
Survey Department, lost one of the most brilliant all-round 
men of science she has ever had. For nearly half a century he 
was the most conspicuous man of science in New Zealand, 
while his persistent journeyings into every nook and corner 
of the land brought him more or less personally into contact 
with every inhabitant of the colony who had any stake in its 
welfare and any share in its publio life and progress. His 
multifarious activities were pursued until between four and 
five years ago, at which date he resigned from the public 
service. At that time he proposed to make a tour with the 
view of exploring the scenes of his Canadian explorations of 
50 years ago—for he was employed on the Palliser Expedi¬ 
tion from 1857 to 1860—but the scheme was abandoned owirg 
to the death of his son and the brief remnant of his life was 
spent in retirement. It is not likely that in the future 
any man will be able to take so commanding a place in the 
scientific life of his country as Sir James Hector did in 
New Zealand, and we cannot do better than quote an appre¬ 
ciation of his many-sided genius from the Wellington Pott 
which has been forwarded to us by our special correspondent 
in the colony. The fact is well brought out in our con¬ 
temporary's sympathetic words that the all-round man of 
science must new be dying out—Sir James Hector was one 
of the last. “ Science was not specialised in the days of Sir 
James Hector's youth as at present and with a vast faculty 
of observation and assimilation, fine reasoning powers, and 
exceptional executive ability, his almost encyclopedic know¬ 
ledge was always at the disposal of his adopted country. 
It may seem paradoxic, but in Sir James Hector's case a list 
of scientific subjects on which he was not a recognised 
authority would be difficult to compile, they were so few. 
At the Philosophical Society he usually left the discussion of 
subjects in the higher mathematics, modern chemistry, or 
optics to others—in practically every other sphere he was on 
even terms with the leading men, and in many supreme. 
His acquaintance with animal and vegetable comparative 
physiology, and biology generally, was marvellous. A bone, 
a wing, a shell—an exceptional structure in any natural 
specimen under discussion—would be the text for 
an extempore discourse scintillating with wit ard 
wisdom, illuminating, fascinating as a fairy tale, and 
invariably supported by original observation. He was a 
thorough meteorologist. His geological attainments were 
world-famous. He knew the physical geography of New 
Zealand and its outlying islands, the contours of its ocean 
deeps, its seismic and thermal lines, ‘ almost as he knew his 
alphabet.’ On the native products of the colony and their 
practical uses he was the leading authority, and he was the 
author, among many other works, of a standard treatise on 
the phormium industry.” Sir James Hector, as might be 
anticipated from such a record, was also prominent in the 
public advancement of science in New Zealand; it was 
always his particular aim to bring home to the people that 
in scientific knowledge, properly organised, must lie social 

salvation. He was one of the founders of the Philosophical 
Institute, which has just issued its thirty-ninth annual 
volume, and he held a prominent position on its council up 
to about five years ago. The Colonial Museum was established 
and built under his care. He organised the New Zealand 
Exhibition of 1865, which was a great success even when 
compared with much later exhibitions having the same object. 
Naturally he was ready to work in any useful directions for 
the development of education, and he became prominent in 
the executive work of the New Zealand University from its 
start. Such is the brief record of a man of most varied 
attainments who served his adopted country so well in many 
ways. His position was always thoroughly recognised by 
his brethren in science. He was associated by friendship 
and correspondence with the leading scientific men of the 
age and honoured by learned societies all the world over. 
In private life his high character, his kindly nature, and his 
genial disposition endeared him to a large circle of friends 
and the gap that he has left will never be exactly filled. 
There is a movement on foot to establish a medal in con¬ 
nexion with the university in commemoration of the great 
work which Sir James Hector did as Chancellor. 



On Dec. 23rd, 1907, an interesting presentation took place 
at the Riyal College of Surgeons of England. Mr. C. R. 
Hewitt, who was recently appointed a librarian at the Royal 
Society of Medicine, being the recipient of a piece of plate 
suitably inscribed and a cheque for 55 guineas in recognition 
of his 22 years’ service in the library of the College. The 
gifts were subscribed for by some 75 friends as a token of 
esteem and good wishes for success in his new appoint¬ 
ment. Professor William Osier made the presenta¬ 
tion ou behalf of the subscribers and in the course of a 
few well-chosen words recalled the valuable help which 
he had received from Mr. Hewitt many years ago 
in the College library. Professor Osier further said how 
pleased he was to see Mrs. Hewitt present on the occasion, 
as the piece of plate—a tea-caddy—would certainly be more 
appreciated by her than by her husband, and he therefore 
felt that he ought to present that to her. Mr. Henry T. 
Butlin, besides thanking Mr. Hewitt personally for the help 
which he had received on many occasions in the library, 
also thanked him on behalf of the Council of the College 
for his valuable assistance and genial manner to the 
readers generally. Mr. Butlin said that the Council 
felt that they had lost an official whose place would he 
difficult to fill. Mr. Hewitt’s new appointment would, how¬ 
ever, give him wider scope in which to show biB ability as a 
library bibliographer. Mr. Hewitt returned thanks for the 
kind words spoken by Professor Osier and Mr. Butlin and 
recorded his appreciation of the sound advice and kind 
assistance that he had received whilst in the service of the 
College from the librarian, Mr. Victor G. Plarr. 


In the Journal of the American Medical Annexation of 
Nov. 9th, 1907, Dr. George Richter has recorded a case of » 
very rare condition—nickel poisoning. The patient was a 
man, aged 24 years, a polisher of aluminium, copper, and 
brass, but mostly of nickel. In the process considerable dust 
was evolved which was only partly removed by “sucking 
blowers.” He consulted Dr. Richter on account of great 
prostration, a sense of pressure on the stomach, and slight 
headache, which he attributed to influenza. His skin was 
pale and bis complexion was sallow. The tongue was 
slightly coated and on its left margin and the corresponding 
buccal surface was extensive leuooplakia. In the evening 


severs pain occurred in the loner abdomen which was not 
increased by pressure. Repeated doses of a third of a grain 
of morphine gave little relief. Magnesium sulphate pro¬ 
duced large evacuations and on the next day there was some 
improvement and the pain was located around the navel 
The urine contained neither albumin nor sugar but was of a 
peculiar light green colour. Fresh urine gave no reaction 
for nickel. 400 cubic centimetres were evaporated and 
incinerated. The ash was treated with hot concentrated 
nitric acid. After the removal of iron the filtrate gave 

with oxalic acid a faint greenish-white sediment, with 
caustic soda a slight greenish sediment, and with 
ammonium Bulphide a brown colour. Blood examination 
showed : haemoglobin 70 per cent., normal erythrocytes, u 
striking number of platelets in aggregation, and normal 
lymphocytes. Under symptomatic treatment and purgation 
recovery took place in ten days. The symptoms thus con¬ 
sisted of cachexia and anaemia followed by severe colic. 
Possibly nickel dust accumulated in the intestines and 
irritated them, and some was converted into a salt and 
absorbed into the blood where it produced the anaemia and 
blood platelets. Possibly also some of the other metallic 
dusts evolved in the patient's work exercised an adverse 
influence. He stated that many of his fellow workers 
frequently complained of ailments which they attributed to 
inhalation of aluminium dust. In the case related above it 
is noteworthy that although the dust was presumably inhaled 
there were no pulmonary symptoms. 


AN ancient folk-song, “The Twelve Apostles,” still sung 
at Chri-tmas and on festive occasions by English rustics, has 
been found on examination to be a variant of the rhythmic 
chant in which the Droids, or medicine-men of the ancient 
Britons, recorded their wisdom. “ The Twelve Apostles ” in 
its Hampshire form is sometimes cited by its first line— 
“ What la your one 0 ? a question that has with its answer 
puzzled whole generations of people curious in such matters. 
In foreign variants of the song, whether Armorican, Slavonic, 
Sonthern German, or even Hebrew, the answer to the open¬ 
ing question is generally a statement of the Unity of the 
Godhead, but the English song differs from all its continental 
parallels in that it retains traces of pre-Christian mysticism, 
quite meaningless at first sight but partially explainable on 
reference to a Celtic version quoted by Aur61ien de Courson 
in hie “ Histoire des Peoples Bretons." “What is yonr one 
O f ”—the Ei glish query—receives the answer, from whioh 
rhyme and reason seem alike to have departed, “ When the 
one is left alone, No more he can be seen 0.” We turn 
to de Courson's version, which must not be confounded 
with the Armorican Church Latin with its “ Unus est 
Deus," and we find a Druid instructor telling his disciple 
that the One is Death. “There is no division for the number 
One, the unique necessity, Death, father of sorrow, nothing 
before, nothing after.” “ Two ” is explained as “ two oxen 
harnessed to an egg-shell. They drag it and they die. 
Behold the marvel.” Then come the “ three beginnings and 
the three endings, for man as for the oak, three celestial 
realms of Merlin, golden fruits, bright flowers, little children 
that laugh” Under these poetic symbols the Druids of the 
pre-Christian period doubtless veiled their teachings, astro¬ 
logical, physical, or medical. Some light is thrown on the 
nature of their medical apothegms by the Hebrew version 
above mentioned, where Nine is the nine months of a 
woman’s gestation (in the English song it is “the triple 
trine,” a mystic reference possibly to the same period). 
What the Druid medicine actually amounted to it is hard 
to say, though the modern Welsh bards still profess to know 
something about it through a kind of MasoDic tradition. The 
Druids’ wives, the Alraunes, are said to have had the care of 

warriors wounded in battle and of women in child-bed. The 
Druids themselves were probably dealers in Bimples and 
astrologers of a rough-and-ready kind, like “ the wise 
women” of our own primitive country-sides. Some Celtic 
herbalist remedies linger, as we know, in the Scottish and 
Irish Highlands and among the descendants of the Cymri on 
both Bides of the Channel. _ 

FOR 1908. 

We are asked to remind our readers that the eighth 
session of the Australasian Medical Congress will be 
held in Melbourne this year under the presidency of 
Professor H. B. Allen, the session commencing on Monday, 
Oct. 19th, and terminating on Saturday, Oct. 24th. The 
subscription is I guinea and will entitle every member te 
a copy of the Transactions of the Congress ; this should be 
sent to the general secretary of the Congress. The railway 
departments of Australasia will issue concession tickets to 
members for the return journey at special rates, par¬ 
ticulars of which will be supplied to intending mem¬ 
bers by the State secretaries. It is anticipated tbat 
reductions in fares, similar to those granted in previous 
years, will be made by the Interstate Steamship Companies. 
The council of the University of Melbourne has granted the 
use of the buildings and the Government of Victoria has 
undertaken the printing of the Transactions. Addresses will 
be given in plenary congress by the presidents of the 
sections of medicine, surgery, pathology and bacteriology, 
and public health, whilst special meetings of the congrees 
will be devoted to the consideration of (a) tbe relations of 
the medical profession to hospitals; and (A) syphilis. Any 
medical man resident in Great Britain desirous of attending 
the Congress or of becoming a member should write to Dr. 
H. C. Maudsley, at 8, Collins-street, Melbourne, who is 
aoting as general secretary._ 


A statement contained in the Bulletin of the Chicago 
School of Sanitary Instruction to the effect that attempts 
are made to introduce children into the public schools on tbe 
strength of their being furnished with certificates from 
medical practitioners stating that the children have been 
" potentized ” reads almost like ancient history. It carries 
us back, indeed, to the days of Lady Mary Wortley Montagu 
who first introduced the system of small-pox inocula¬ 
tion into this country from Constantinople. Apparently, 
however, “ potentization ” Is usually induced by adminis¬ 
tering “ variolinum ” internally, this substance being pre¬ 
pared by triturating “ matter ” from a ripe small pox vesicle 
with sugar of milk. Sometimes, however, tbe “ varioliuum ” 
is rubbed on the arm. It is stated that, unlike inoculation, 
“ potentization ” has no protective influence over small-pox 
and that children thus treated may be easily vaccinated. But 
although we are told that this “ potentization ” is not re¬ 
cognised by health authorities no mention is made as te 
whether or not this custom has led to the spread of small¬ 
pox or why, as with inoculation in this country, the operation 
is not forbidden by law. Perhaps later issues of tbe Chicago 
Bulletin will contain additional data relative to this “potenti¬ 
zation ’’ and as to its historical relationship to the practice 
adopted by the Chinese of inserting small-pox crusts into the 
nostrils of the patients in order apparently that they might 
contract tbe disease by inhalation. It is difficult to ascertain 
whether there were amongst the Chinese any conscientious 
objectors to this crusting process but in so far as inoculation 
or eDgralting is concerned it would appear from the writings 
of Madame Sevigi.6 in 1718 tbat in Adrianople “every 
year thousands undergo the operation, and the French 
Ambassador says pleasantly tbat they take the small-pox 

42 The Lancet,] 


[Jan. 4, 1908. 

here by way of diversion as they take the waters in other 
countries. There is no example of anyone who has died in 
it, and you may believe I am well satisfied of the safety of 
this experiment since I intend to try it on my dear little 
son.” As to the practice of inoculation in this country, 
there are probably persons still alive who underwent the 
operation, although none are likely to remember that the 
charge for the operation amoDgst medical practitioners was 
about half a guinea. But in those days there were no 
public vaccinators and hence no opportunities for boards of 
.guardians to accord them the minimum fees. 


Thb issue of this work for 1908 appeared with commend¬ 
able promptitude in the third week of December, 1907. 
Comparing the edition for the current year with that for the 
year just past we see that the total number of names for 
1903 is 39,703, as against 39,365 for last year, being an 
increase of 338. As regards the several regions into which 
the Directory is divided the number of names in the London 
list for 1908 is 6550, as against 6512 in 1907. The pro¬ 
vincial list for England for 1908 contains 17,211 names, 
as against 17,080 in 1907 ; Wales for 1908 has 1256 
names, as against 1232 for 1907; Scotland for 1908 
has 3829 names, as against 3815 for 1907. The 
Irish list for 1908 contains 2660 names, as against 2672 for 
the past year. The list of practitioners resident abroad 
contains 4927 names, as against 4822 in 1907. The Naval, 
Military, and Indian Medical Services for 1908 number 3259 
names, as against 3223 in 1907. It will tans be seen that 
there is a recorded increase in the cnmbers of the profession 
in every part of the kingdom except Ireland. The "Too 
Late” list for this year contains 11 names, two more than 
in 1907. The introductory chapter on the legal relations of 
medicine has become an acknowledged authority for refer¬ 
ence, and as is universally known in the medical profession 
Messrs. J. and A. Courchili are the publishers of this 
indispensable work of reference. 


One of the most subtle forms of adulteration in the 
present day is the admixture of cocoanut oil with butter fat, 
the product being sold as genuine batter. Indeed, it has 
been asserted that almost pure cocoanut oil has been palmed 
off as pure butter. Hitherto the analyst has been balllad in 
his attempts at devising a method for the certain detection 
cf cocoanut oil in butter, the sophistication being so 
cleverly accomplished that the mixture on examination is 
found to yield certain analytical factors which are consistent 
with those yielded by genuine butter itself. It is singularly 
opportune in view of the new measure for the control of the 
sale of butter which comes into force this year that a method 
has been projected which promises to place in the hands 
of the analyst a means of detecting this sophistication. In 
a note contributed to the Chemical A’emt of Dec. 20th, 
1907, Mr. T. R. Hodgson, B.A., A.I.O., of the analytical 
department of the University of Birmingham, shows that the 
oxygen equivalent of cocoanut oil is considerably less than 
that of pure butter fat. The oxygen equivalent is found by 
submitting the pure fats to the action of a standard 
solution of potassium permanganate for a time and 
afterwards determining the amount of permanganate left 
unreduced. One gramme of the filtered fat is weighed 
out into a flask and 25 cubic centimetres of a half normal 
alcoholio solution of caustic potash are added. The whole 
is heated under a reflux condenser for 30 minutes. After the 
saponification is complete the flask is detached from the con¬ 
denser and the solution is evaporated to dryness. Distilled 
water is added to the residue and the whole is evaporated 

once more to dryness. The process is repeated until the 
whole of the alcohol has been dissipated. The residue is next 
dissolved in water and made up to 1000 cubic centimetres. 
20 cubic centimetres are measured out and placed in a 
beaker and 50 cubic centimetres of a tenth normal solution 
of potassium permanganate are added and finally 50 cubic 
centimetres of a 50 per cent, solution of sulphuric acid. 
The beaker is then placed on the water bath (100° C.) for 
half an hour and the excess of permanganate is then deter¬ 
mined by means of a standard solution of ferrous ammonium 
sulphate. The number of cubic centimetres of permanganate 
solution used multiplied by 4 gives the “oxygen equivalent,” 
or the number of grammes of oxygen required to oxidise 100 
grammes of the oil or fat. Pure butter fat gives an oxygen 
equivalent of 167 • 2. With 10 per cent, of cocoanut oil 
present the equivalent is 160'8, with 20 per cent. 152, with 
30 per cent. 142 1 4, with 40 per cent. 136 1 0. with 50 per 
cent. 127 • 2, with 60 per oent. 118 • 4. with 70 per cent. 
110 • 4, with 80 per cent. 103 2, with 90 per cent. 95 ■ 2, 
until pure cocoanut oil itself gives 87 • 2 as the “oxygen 
equivalent.” It is to be hoped that this method will prove 
on continued trials to give trustworthy results and so to 
supply at last to the analyst a means of bringing to light 
a very subtle form of adulteration. 


At a meeting of the Metropolitan Asylums Board on 
Saturday, Dec. 7th, it was unanimously decided, on the 
motion of Dr. W. R. Smith, 

That, in view of the continued prevalence of scarlet fever, notwith¬ 
standing the extensive isolation accommodation which has been pro¬ 
vided, the Local Government Board !»o asked to cause an inquiry to he 
instituted into the cause of this disease; and whether any, and if so 
what, further means can l>e adopted for ita prevention. 

Dr. Smith submitted a table of figures which showed that in 
1890 there were 15.330 cases of scarlet fever notified, ora 
ratio per 1000 of population of 3 7; in 1906 the cases 
notified numbered 20.329 or a ratio per 1000 of population 
of 4 3. In the acquisition of sites the Board had expended 
£234.104 and the cost of buildings and equipment amounted 
to £2,905.659. For that expenditure they had provided 
8166 beds and they were in no way better off from the poiDt 
of view of the spread of infectious disease by reason of that 
vast expenditure. _ 


In The Lancet of August 20th, 1904, we commented 
favourably upon some lectures given by Miss Charlotte 
Smith Kosaie to women prisoners in Portsmouth jail. The 
lectures were upon the subjects of hygiene and the care of 
children. An article by Miss Rossle appears in the current 
number of The Semday at Home in which she gives an 
account of some lectures which she delivered to sundry 
women prisoners who were undergoing punishment for 
cruelty to children. This offence, disgraceful as it is 
to have to say so, iB by no means confined to the 
injutta » overoa, who has throughout the ages gained an 
evil reputation, bat in many cases mothers are as hideously 
cruel as it is possible to conceive. Miss Rossie claims 
to have influenced these prisoners for good and she makes 
one suggestion which seems to us worthy of notice by experts 
in prison sociology. It is that “ cruelty ” prisoners should 
not be put in a “star" class, for that means a privileged 
class, but that they should be placed in a separate class from 
the ordinary criminal, ‘‘as for the most part they are 
respectable married women ” and an attempt should be made 
to teach them home duties. This, we think, is a good 
suggestion, for the average modern woman is singnlarly 
ignorant of home duties and of the commonest laws of 

The Lancet,] 


[Jan. 4,1908. 43 

health. Hence nearly every woman’s paper contains a column 
generally headed “ Health and Beauty ” or some similar title, 
in which correspondents ask idiotic questions and in many 
instances get equally idiotic answers. IF Miss Rossis would 
add to her labours in the instruction of prisoners by instruct¬ 
ing those outside prisons as well, avoiding, of course, medical 
questions, she would be deserving of the gratitude of many. 



The opening of the grave of the late Mr. T. C. Druce at 
Highgate has set at rest the doubt which apparently existed 
in some minds as to whether the coffin bearing his name and 
placed in his family vault in 1864 might contain nothing 
more than rolls of lead used for purposes of deception at 
a mock funeral. It is difficult to understand such doubts 
affecting anyone who heard or read the evidence given 
at the hearing in the Probate Division in December, 
1901, 1 unless he believed that the grave might have 
been tampered with since the incidents then deposed to 
by the medical witnesses took place. It is not too much 
to say that if no human remains had been found in the coffin 
opened on Dec. 30th last the only alternative to a theory 
of interference subsequent to the funeral would have been 
the supposition that not only Mr. Herbert Druce but Dr. 
Edmund Shaw and his partner, Mr. W. Blasson, as well as 
the housekeeper, Catherine Ann Bayley, committed deliberate 
perjury in the suit tried before Mr. Justice Gorell 
Barnes. Their evidence was perfectly clear that a 
gentleman well known to them as Thomas Charles Druce, 
who had been ill for some time and who had been 
operated upon by Sir William Fergusson, died and was by 
them placed in his coffin, which they, or some of them, 
followed to the grave. At the same trial a statement, since 
frequently repeated, to the effect that there was an irregularity 
in the certificate of the cause of death in that it did not bear 
the signature of any medical man, was fully explained, the 
simple explanation being that in 1864 the law did not require 
death certificates to be signed. The effect of the recent 
exhumation has been to corroborate the evidence of two 
medical practitioners of unimpeachable integrity, inde¬ 
pendent witnesses whose testimony was in no way shaken 
when it was originally given, and which consequently 
required nothing to confirm it, but at the same time 
the popular interest in the matter and the unwilling¬ 
ness of the public to be undeceived rendered the 
opening of the coffin, with the resulting ocular demonstra¬ 
tion that it contained a dead body, desirable. What this 
result may be upon the litigation which in various forms 
is still pending, and upon public opinion with regard to it, 
we do not, of course, discuss. 

TnE second annual dinner of the past and present students 
of the Royal London Ophthalmic Hospital will take place at 
the Trocau (ro Restaurant, Shaftesbury-avenue, W., on 
Wednesday, Jan. 29th, at 7.45 for 8 p.m., with Sir John 
Tweedy, consulting surgeon to the hospital, in the chair. 
Each student is entitled to introduce two guests and 
tickets (price 10». 6 d. each, exclusive of wine) may be had on 
application to either of the honorary secretaries, Mr. Arnold 
Lawson, 12, Harley-street, London, W., and Mr. J. Herbert 
Parsons, 27, Wimpole-street, London, W. 

The opening lecture of the Mount Vernon Hospital post¬ 
graduate course will be given by Sir Thomas Clifford All butt, 
F.R.8., consulting physician to the hospital, in the lecture 
room at the central out-patient department. 7, Fitzroy-sqnare, 
Loudon, W... on Thursday, Jan 9th, at 5 P.M. The subject 

of the lectnre, to which medical practitioners are invited, 
will be Angina Pectoris. _ 

A telegram from the Governor of the Mauritius received 
at the Colonial Office on Dec. 27th, 1907, states that for the 
week ending Dec. 26th there were one case of plague and 
one death from the disease._ 

Mr. C. A. Ballance has been elected an honorary fellow of 
the American Laryngological, Rhinological, and Otological 
Society. _ 

Mr. Malcolm A. Morris, F.R.C.S. Edin., has been appointed 
a Knight Commander of the Royal Victorian Order. 

Jnlrlic pealt|j aitb ^aor fafo. 



On the Sanitary Circumstances and Administration of the 
Urban District of Whitby , by Dr. R A. Farrar. 1 — Whitby, 
already described in 1538 as “a great fischar towne,” had 
become a prosperous seaport in the reign of Queen Elizabeth, 
when it did a good trade in the manufacture of alum. In 
1753 the town entered on a new era, as ships began to sail 
from Whitby to the Greenland seas for whale fishing. 
Following on the whale fishing came a period of wooden 
ship-building which gave place to an iron ship-building 
industry which has only ceased within the last few years 
owing to the insufficiency of the harbour. The decay 
in ship-building was for a time more than compen¬ 
sated by the development of the jet trade. In the 
early days of Queen Victoria’s reign, particularly after the 
death of the Prince Consort, jet ornaments had an extra¬ 
ordinary vogue and at one time as many as 1400 hands 
were employed in their manufacture. “Line” and herring 
fishing brought some prosperity to the town until a few years 
ago, but the silting of the harbour has rendered the passage 
of the harbour bar so unsafe that the port has practically 
been abandoned by all but a few local fishing cobles. At the 
present day Whitby’s only source of prosperity is its annual 
influx of summer visitors and excursionists. All these 
vicissitudes have left their mark, as Dr. Farrar shows, on the 
housing conditions of the town. As the whale fishing and 
ship-building industries increased the good and substantial 
houses on the East Cliff were surrounded or superseded by an 
abundance of jerry-built houses and narrow courts. When 
the jet industry flourished jet factories and warehouses were 
crowded into every corner which could be made available. 
The “slums” of Whitby, about which there has lately been 
much local agitation, are in consequence of these conditions 
slums in a very real sense. Not only is the crowding on 
area excessive, and greatly aggravated by the presence of 
derelict jet factories, but the courts and dwellings themselves 
are in many cases beyond repair and though occupied are 
quite unfit for human habitation. The entries into the 
courts are seldom more than three feet wide and the passages 
dividing the blocks of houses have generally a like width. 
The lower rooms are in consequence almost invariably dark. 
Many of the houses are damp owing to the walls being built 
against the hillside. The bedrooms are often mere cup¬ 
boards contrived in the living room, containing less than 
ZOO cubic feet air space and kept closed in the daytime. Dr. 
Farrar has no doubt that the health of the inhabitants of 
these slum areas in Whitby suffers from the conditions of 
living which result from the character of these dwellings. 
In examining the school children he found that the physical 
condition of those on the east side of the town was markedly 
inferior to that of children on the west, and, in particular, 
children from one of the collections of “slum” courts could 
by their physical deterioration be as a rule picked out at a 
glance from the other scholars. The report points out that 

1 London: Wyman and Sons, Fetter-lane; Edinburgh: Oliver and 
Boyd; Dublin: E. Ponsonby. No. 287. Price 4cl. 

1 The Lancet, Dec. 14tb, 1901. 

44 The Lancet,] 


[Jan. 4,1908. 

the first proceeding necessary is to treat derelict tenement 
blocks, jet factories, and warehouses as obstructive buildings 
under the Housing of the Working Classes Act, with a view 
to letting in light and air to the remaining blocks. This 
could be done, Dr Farrar notes, “without seriously impair¬ 
ing the effect of the huddle of red roofs which is one of the 
aesthetic charms of Old Whitby.” The space thus gained 
could be utilised as open space in a variety of useful ways, 
and the authorities concerned should then use their powers 
to secure that the remaining bi cks are put into habitable 
repair. Along with these measures it is desirable that a certain 
number of modern working-class dwellings should be erected. 
Action by the district council on these lines has been success¬ 
fully taken at Alnwick and other old towns presenting 
similar problems. The district council, in the hope of re¬ 
habilitating the ship building and filing industry of Whitby, 
is proposing to spend no less than £95 000 on harbour 
extensions and improvements and on the rebuilding of 
Whitbv bridge. If the anticipation of increased prosperity 
is just,ifind it will be essential to provide for increase in, and 
improvement of, the house accommodation which is avail¬ 
able for the working-class population. If the anticipation is 
unlikely to be justified (and in view of recent extensions of 
competing ports the proposal seems open to some doubt) the 
Whitby council would probably be serving its town better by 
abandoning grandiose schemes and by spending a much more 
moderate sara on housing improvements which at least may 
be relied upon to yield a return in the form of the better 
health and physical conditions of the population. 

On the Solitary Circumstances and Administration of the 
T/iingoe Rural District , by Dr. F. ->t George Mivart 3 — 
Many interesting matters are dealt with in this report which 
relates to a large rural district with some 14 000 inhabitants 
surrounding the borough of Bury St. Edmunds Among 
these are the insanitary conditions of dairy farms, many of 
which supply London dairy companies, and the unsatisfactory 
conditions of housing which prevail. The want of more 
cot ages is “ bitterly felt” in this district, and this is little 
to be wondered at in view of the character of many of those 
which now exist. Dr. Mivart reports that often houses were 
in a ruinous condition, the holes in the plaster walls being 
plugged with old sacks and rags within or blocked with a 
piece of plank and odds and ends of timber without. Such 
houses were also leaky in other places—e.g., round the door 
and window frames, and occupiers resort to all sorts of 
expedients to prevent the entrance of cold air in winter 
Riin-water pipes when present are commonly broken and 
while allowing the water to stream down the house walls 
deliver it also upon the ground in proximity to founda¬ 
tions, t* e surface about the house being only in a 
few instances furnished with paving. As to cottage 
bedrooms the report points out that sometimes the first- 
floor sptee comprises two or three rooms, of which the back 
one has no direct supply of light and air at all. The 
following account of a cottage in Sicklesmere is given aR an 
instance of the use to which first-floor space may be put 
without bringing about prosecution for overcrowding :— 
“Total first floor spac*, about 13 X 15 X 7 feet = about 
1365 cubic feet of space. A corner of this, sufficient to 
hold a bed. is screened off by a dwarf partition about 4 feet 
6 inches high. The entire first-floor space is shared by six 
persons, viz . a widow, aged 40; two sons, aged 16 and 14 ; two 
daughters. at?ed 13 and 6 ; and, as a logger, a brother-in law, 
aged about 50 No fireplace or back window. Ventilation 
only by front window 2 feet square and by the opening in 
the floor for the ladder staircase.” In the living rooms the 
fireplaces are often so poor that “cooking of any useful 
kind would be almost impossible even if inmates had 
sufficient knowledge for this.” Many cottage dwellings 
are going steadily to ruin There is special difficulty in 
getting repairs in “ tied ” cottages—ie., those rented by the 
farmers for their labourers. It is some iroes said that 
stringency of building by-lawg prevents building in rural 
areas, hut in this district no by-laws as to new buildings are 
in force. It should be said, however, that the di*.r,rict 
council m ide an attempt some years ago to utilise the 
Housing of the Working C asses Act. Eight good semi 
detached cottages in fonr blocks, with sufficient land, were 
erected at Ixworth in 1893 at a cost of £1700, obtained by 
loan reptyaole in 30 years. The innovation was suhje ted to 
much local criticism and ridicule under the name of the 
“Tbingoe Folly.” But Dr Mivart found the houses all 

* Ibid., No. 286. Price 4 d. 

occupied ; he gives the profit and loss account in connexion 
with them, and shows that when the loan is extinguished 
the council is likely to find itself well on the right side of the 
account. The experiment suggests that subject to some altera¬ 
tions, such as lengthening the borrowing period, it would 
be practicable to do much good by similar “follies” in 
other villages and hamlets. Too much stress must not 
be laid on the argument that properly built cottages of this 
kind must be let at a higher rent than the labourer can 
afford. Those who can afford the rent and go into these 
cottages in most cases vacate a better kind of cottage for the 
labourer to move into, and advantage can be taken of the 
process of “ moving up ” to compel demolition or satisfactory 
repair of the worst kinds of dwellings. 

On the Prevalence of Diphtheria at Ringmer , by Dr. R. J. 
Reece 8 —This report relates to a persistent prevalence of 
diphtheria in a little village in Su-sex which appears to 
have beeD sp-^ad through the agency of the village school 
and to ha\e continued notwithstanding frequent but short 
periods of school closure. The account given by Dr. Reece 
affords one more illustration of the danger of concluding that 
children are no longer capable of carrying infection because 
a single examination of a “ swab ” from the throat has given 
a negative result as regards the presence of the bacillus diph¬ 
theria;. It also affords a good instance of the way in which 
apparently healthy children may harbour the diphtheria 
bacillus in the throat or nose. At the end of September, 
when the disease had been prevalent in the school for 
some nine months, Mr. A. G. R Foulerton made a bacterial 
examination of swabs from 48 children in Standard I., with 
the result that the diphtheria bacillus was found to be 
present in the throat or nasal cavity of 14 of these children. 
Dr. Reece gives the text of a series of recommendations made 
to the local authority with a view to check the further 
spread of the disease: these include the isolation of 
“infected” and “suspected” cases until they are proved 
bacfceriologically to be free from infection, and the provision 
of temporary accommodation for the isolation of suspected 



In 76 of the largest English towns 8435 births and 5160 
deaths were registered during the week ending Dec 21st, 1907, 
The annual rate of mortality in these towns, which had been 
16 0 and 16 1 per 1000 in the two preceding weeks, 
further rose to 16 8 per 1000 in the week under notice. 
During the first 12 weeks of the quarter the death-rate 
averaged 15 7 per 1000, the rate during the same period 
being 14'9 in London. The lowest death-rates in the 
76 towns were 6 0 in Bournemouth, 8 0 in East Ham. 
8 7 in H-indsworth (Staffs), 9 3 in Hornsey, and 9 9 
in Great Yarmouth ; the highest rates were 24 1 in 
Sunderland, 24 ‘2 in Rotherham, 25 • 6 in Bootle, 25*7 in 
Tynemmi'h, 26 0 in Merthyr Tydfil, and 28 9 in Preston. 
The 5160 deaths in these towns exceeded by 206 the 
number in the preceding week, and included 398 which 
w^re referred to the principal epidemic disea^-es, against 
388 and 374 in the two preceding weeks; of these, 
124 resulted from measles, 94 from whooping-cough, 
62 from diphtheria, 50 from scarlet fever, 48 from diar¬ 
rhoea, and 20 from “fever” (principally enteric), but not 
any from small-pox. No deaths from any of these epidemic 
diseases were registered in Leicester, Blackburn, Brighton. 
Plymouth, Leyton, Stockport, or in nine other of the 76 
towns ; the annual rates from these diseases, however, ranged 
upwards to 3 1 in Aston Manor, 3’3 in Salford, 3'8 in 
Tynemouth, 4 8 in Rhondda, 5*1 in Barrow-in Furness, and 
6 2 in Bootle. The deaths from measles, which had been 111 
and 107 in the two preceding weeks, rose again to 124 in 
the week under notice, the highest rates being 1*7 in Gates¬ 
head. 1 8 in Salford, 1 • 9 in Leeds, 2 * 1 in Willesden 3 • 6 in 
Rhondda, 3 8 in Tynemouth, and 5*1 in Barrow-in-Furness. 
The fatal cases of whooping-cough, which had been 107 and 95 
in the two preceding weeks, declined to 94. and caused death- 
rates ranging upwards to l'l in Northampton, 12 in 
Rochdale, 13 in Sunderland, 1*4 in Ipswich and in Kings 
Norton, 2 • 5 in Aston Manor, and 4 ■ 7 in Bootle. The deaths 
from diphtheria, which had been 60 and 67 in the two pre¬ 
vious weeks, rose again to 62, the greatest proportional 

* Ibid., No. 290. Price 3d. 

Tub Lancet,] 


[Jan. 4,1908. 45 

mortality being recorded in H-mdley and in Bootle, where 
the rate was I ■ 6 per 1000. The 50 fatal cases of scarlet 
fever exceeded the numbers registered in any of the seven 
preceding weeks ; the highest death-rate from this disease 
was 1 0 per 1000 in Burnley. The deaths from diarrhoea, 
which had been 89, 50, and 47 in the three preceding weeks, 
were 48 in the week under notice, and caused death-rates 
ranging upwards to 1 • 1 in Walsall and 1 1 4 in Merthyr 
Tydfil. “ Fever ” was not excessively fatal in any of the 76 
towns. The number of scarlet fever cases under treatment in 
the Metropolitan Asylums Hospitals and the London Fever 
Hospital, which had been 5676, 5581, and 5352 at the end 
ot the three preceding weeks, had further decreased to 
6035 on Saturday, Dec. 21st.; 447 new cases were admitted 
daring the week, against 623, 554, and 500 in the three 
preceding weeks. The deaths in London referred to 
pneumonia and other diseases of the respiratory organs, 
which had been 388, 355, and 348 in the three preceding 
weeks, were 347 in the week under notice, and were 94 below 
the corrected average number in the corresponding periods of 
the five years 1902-06 The causes of 36, or 07 percent., 
of the deaths in the 76 towns were not certified either by a 
registered medical practitioner or by a coroner. All the 
causes of death were duly certified in Leeds, Bristol, West 
Ham, Bradford, Newcastle-on Tyne, and in 56 other towns ; 
six uncertified deaths were registered in London, six in 
Sheffield five in Birmingham, five in Liverpool, and two 
each iD Preston, Gateshead, and Khondda. 

During the week ending Dec. 28th, 5860 births and 4527 
deaths were registered in 76 of the largest English towns. 
The annual rate of mortality in these towns, which had been 
16 0, 16 1, and 16'8 per 1000 in the three preceding weeks, 
declined again last week to 14 7 per 1000. During the 13 
weeks of the quarter the death-rate averaged 15 5 per 1000, 
the rate in London during the same period being 14 9 The 
death-rates in the 76 towns last week ranged from 6 9 in 
King’s Norton, 7 0 in Hastings 7'4 in Southampton, and 
7'6 in Eist Ham to 22 8 in Rhondda, 23 6 in Wigan. 23 6 
in Ipswich, and 24'4 in South Shields. The 4627 deaths 
registered in the 76 towns last week were 633 fewer than the 
number in the previons week, and included 373 which were 
referred to the principal epidemic diseases, against 374 and 
398 in the two previous weeks; of these 373 deaths 105 
resulted from measles, 89 from whooping-cough, 71 from 
diphtheria, 44 from diarrhoea, 41 from scarlet fever, 
and 23 from “fever” (principally enteric), but Dot any 
from small-pox. No deaths from any of these epidemic 
diseases were registered last week in Hastings, Bournemouth, 
Reading, Handsworth (Staffs), Smethwick, Coventry, 
Wallasey, or West Hartlepool ; among the other towns the 
death rates from these diseases ranged upwards to 3 6 in 
Rhondda, 3 9 in Burton-on-Trent, 4 8 in Tynemouth, and 
9'3 in Ipswich. The fatal cases of measles, which had been 
107 and 124 in the two preceding weeks, declined again to 
105 last week, and caused death-rates ranging upwards to 
1 ■ 3 in Salford, 1'6 in Bootle, 1 • 7 in Barrow-in-Furness and 
in Leeds, 2'7 in Swansea, 2 9 in Burton-on-Trent, 3 8 in 
Tynemonth, and 7 2 in Ipswich The deaths from whooping- 
cough, which had been 107, 95, and 94 in the three preceding 
weeks, further fell to 89 in the week nDder notice, the highest 
death-rates from this disease beiDg 1 ■ 1 in Northampton, 1 3 
in Devunport, in Aston Manor, in Sunderland, and in New¬ 
castle on-Tyne, 1-4 in Ipswich, and 1 ■ 6 in Hanley and in 
Bootle. The fatal cases of diphtheria, which had beeD 57 and 
62 in the two previous weeks, further rose last week to 
71; this disease was proportionally most fatal in Norwich, 
where it caused a death-rate of 1 ■ 3 per 1000. The deaths 
from diarrhoea, which had been 47 and 48 in the two pre¬ 
ceding weeks, deolined again to 44 in the week under 
notice ; the mortality from this disease was not excessive in 
any of the large towns. The fatal cases of scarlet fever, 
which had been 38, 40, and 50 in the three preceding weeks, 
fell to 41 last week, and caused death-rates ranging upwards 
to 1 1 1 in Walsall, 2' 1 in Newport (Mon,), and 2 ‘3 in West 
Bromwich. The 23 deaths referred to “fever ” were three in 
excess of the number iD the previous week, the highest death- 
rate from this cause being 1 1 in Northampton. There were 
4999 scarlet fever patients under treatment in the Metro¬ 
politan Asylums Hospitals and the London Fever Hospital at 
the end of last week, against 5581. 5352, and 5035 at the end 
of the three preceding weeks ; 353 new cases were admitted 
during the week, against 554, 500, and 447 in the three pre¬ 
ceding weeks. The deaths in London referred to pneumonia 
and other diseases of the respiratory organs, which had been 

365, 348, and 347 in the three preceding weeks, further 
declined to 317 in the week under notice and were 145 below 
the corrected average number in the corresponding periods 
of the five preceding years, 1902-06. The causes of 56, or 
1 2 per cent., of the deaths registered in the 76 towns were 
not certified, either by a registered medical practitioner or 
by a coroner. AH the causes of death were duly certified in 
Bristol, West Ham, Bradford, Newcastle-on-Tyne, and in 42 
other towns; seven uncertified deaths were registered in 
Liverpool, six in Birmingham, five in WarriDgton, three in 
Manchester, and two in each of nine other towns. 


The annual rate of mortality in eight of the principal 
Scotch towns, which had been 19 ■ 3, 20'6, and 20 0 per 1000 
in the three preceding weeks, increased to 20 ■ 8 per 1000 
during the week ending Dec. 21st, 1907, and was 4 0 per 
1000 above the mean rate during the same period in 
the 76 large English towns. The rates in the eight Scotch 
towns ranged from 13'7 in Aberdeen and 18 0 in Edin¬ 
burgh to 27'4 in Leith and 30 1 5 in Dundee. The 724 
deaths in these towns were 28 more than the number in 
the previous week, and included 126 which were referred 
to the principal epidemic diseases, against 111, 132, aDd 
127 in the three preceding weeks ; of these, 53 resulted 
from measles, 26 from whooing-cough, 14 from diarrhcea, 
11 from diphtheria, seven from cerebro-spinal menirgitis, 
three from scarlet fever, and two from enteric iever. 
These 1 -6 deaths were equal to an annual rate of 3 • 3 
per 1000, which was 2 0 per 1000 above the mean rate 
during the same period in the 76 large English towns. The 
fatal cases of measles, which had been 79 and 71 in the two 
previous weeks, fnr; her declined to 53 in the week under 
notice, and included 35 iD Glasgow, 10 in Dundee, and five 
in Greenock. The deaths from whooping cough, which had 
been 13 and 24 in the two preceding weeks, farther rose to 
26 of which 11 occurred in Glasgow, four in Edinbnrgh, 
four in Aberdeen, three in Perth, aDd two in Greenock. The 
fatal oases of diarrhcea, which bad been 36, 21, and 18 in the 
three preceding weeks, farther declined to 14 in the week 
under notice, and included eight in Glasgow and four in 
Edinbnrgh. The deaths from diphtheria, which had been 
nine and eight in the two previous weeks, increased again to 
11, of which three occurred in Glasgow, three in Paisley, 
and two in Leith. Of the seven deaths from cerebro-spinal 
meningitis three were registered in Glasgow, two in Pai-ley. 
and one each in Edinbnrgh and Leith. The deaths referred 
to diseases of the respiratory organs, including pneumonia, 
which had been 167 and 161 in the two preceding weeks, 
further declined to 157 in the week under notice, but were 
38 above the number in the corresponding week of last year. 
The canses of 25, or 3’5 per cent., of the deaths in the 
eight Scotch towns were not certified or not stated ; in 
the 76 English towns the proportion of uncertified deaths 
registered during the same week did not exceed 0'7 
per cent. 

Daring the week ending Saturday last, Dec. 28th, the 
annual rate of mortality io the eight Scotch towns was 18 ■ 2 
per 1000. against 20.' 6, 20 0, and 20 8 per 1000 in the three 
preceding weeks, and was 3‘5 per 1000 above the mean rate 
last week in the 76 large English towns. Among the Scotch 
towns the death-rates ranged from 12 • 5 in Leith and 13'2 
in Aberdeen to 24 2 in Greenock and 25 4 in Perth. The 
632 deaths registered in these towns last week were 92 fewer 
than the number in the preceding week, and included 109 
which were referred to the principal epidemic diseases, 
against 132. 127, and 126 in the three precedir g weeks ; of 
these 53 resulted from measles, 24 from whooping-cough, 14 
from diarrhoea, seven from diphtheria, five from scarlet 
fever, three from enteric fever, aDd three from cerebro¬ 
spinal meningitis, but not any from small-pox. These 
109 deaths were equal to an annual rate of 3 1 per 
1000, which was 1 ■ 9 per 1000 above the mean rate last 
week from the principal epidemic diseases in the 76 large 
English towns The fatal cases of measles, which had 
been 79, 71. and 53 in the three preceding we. ks, were again 
53 last week, and included 38 in Glasgow, eight in Dundee, 
lour in Greenock, and two in Aberdeen. The deaths from 
whooping-cough, which had been 13 24, and 26 in the three 
preceding weeks, declined again last week to 24. of which 
six occurred in Glasgow, six in Perth, three in Edinbnrgh, 
three in Dundee, three in Leith, and two in Greenock. The 
fatal cases of diarrhoea, which had been 21, 18, and 14 in the 

46 Tbs Lancet,] 


[Jan. 4, 1906. 

three preceding weeks, were again 14 in the week under 
notice, and included five in Glasgow, three in Aberdeen, two 
in Edinburgh, two in Dundee, and two in Paisley. The 
deaths from diphtheria, which bad been eight and 11 in the 
two preceding weeks, declined last week to seven, of 
which four were registered in Glasgow. The fatal 
cases of scarlet fever, which had been three in each of 
the two previous weeks, rose last week to five, and included 
three in Glasgow, where the three deaths from cerebro¬ 
spinal meningitis also were registered. The deaths referred 
to diseases of the respiratory organs in these eight towns, 
which had been 167, 161, and 157 in the three preceding 
weeks, further fell to 127 in the week under notice and were 
40 below the nnmber in the corresponding period of last year. 
The causes of 26, or 4 1 per cent., of the deaths in these 
towns were not certified or not stated ; in the 76 English 
towns the proportion ot uncertified deaths was 1 2 per cent. 


The annual rate of mortality in Dublin, which had been 
26 ■ 7 and 22 ■ 3 per 1000 in the two preceding weeks, rose again 
to 25'0 per 1000 in the week ending Dec. 21st, 1907. During 
the first 12 weeks of the current quarter the death-rate 
averaged 21 7 per 1000, the rate during the same period 
being 14 ■ 9 in London and 14 • 4 in Edinburgh. The 187 
deaths of Dublin residents registered during the week under 
notioe were 20 in excess of the number in the previous 
week, and inoluded ten which were referred to the 
principal epidemic diseases, against four, nine, and six in 
the three preceding weeks ; of these, four resulted from 
diarrhoea, three from diphtheria, two from whooping-cough, 
and one from scarlet fever, but not any from small pox, from 
measles, or from “fever.” These ten deaths were equal 
to an annual rate of 1'3 per 1000, the death-rates 
during the same week from the principal epidemic 
diseases being 1 0 in London and H in Elinburgh 
The four fatal cases of diarrhoea exceeded the numbers in 
the three preceding weeks; the three deaths from diphtheria 
corresponded with the number in the previous week. The 
187 deaths from all causes in Dublin during the week 
under notice included 40 of children under one year 
of age and 53 of persons aged upwards of 60 years ; there 
numbers were respectively 13 and five in excess of the 
corresponding numbers in the previous week. Eight inquest 
cases and six deaths from violence were registered ; and 
78, or 41'7 per cent., of the deaths occurred in public 
institutions. The causes of four, or 2 ■ 1 per cent., of the 
deaths registered in Dublin during the week were not certified ; 
in London the proportion of uncertified deaths was 0'4 per 
cent,, while in Edinburgh the proportion was not less than 
9 • 2 per cent, of the total deaths. 

In the week ending Dec. 28th the annual rate of mortality 
in Dublin was 19 8 per 1000, against 22 • 3 and 25 • 0 per 
1000 in the two preceding weeks. Daring the past 13 
weeks the death rate has averaged 21 * 5 per 1000. the rates 
during the same period being 14 • 9 in London and 14 • 6 in 
Edinburgh. The 148 deaths of Dublin residents registered last 
week were 39 fewer than the nnmber in the three preceding 
week, and included five which were referred to the principal 
epidemic diseases, against nine, six, and ten in the three pre- 
cedingweeks ; of these, two resulted from whooping-cough, one 
from scarlet fever, one from diphtheria, and one from “ fever,” 
but not any from small-pox, measles, or diarrhoea. These five 
deaths ware equal to an annual rate of 0 ■ 7 per 10-0, the 
death-rates last week from the principal epidemic diseases 
being 0 9 in London and 1 ■ 1 in Edinburgh. The 148 
deaths from all causes in Dublin included 25 of children 
under one year of age and 38 oE persons aged upwards of 60 
years ; the deaths both of infants and of elderly persons 
showed a decline of 15 from the respective numbers recorded 
in the previous week. One inquest case and two deaths 
from vi lence were registered, and 54, or 36 5 per cent., of 
the death- occurred in public institutions The causes of 
three, or 2 0 per cent., of the deaths in Dublin la»t week 
were not certified ; in London only two of the 1326 deaths 
were uncertified, while in Edinburgh the proportion was 4 5 
per cent, of the total deaths. 

West London Post-Graduate College.—T he 

next ses-ion of th-s College will commence on Monday, 
Jan. 13th, and will last for 12 weeks. 


Royal Navy Medical Service. 

In accordance with the provisions of Her late Majesty’s 
Order in Conncil of April 1st, 1881, Fleet-Surgeon William 
Gordon Stott has been placed on the Retired List at his own 
request (dated Dec. 29th, 1907). Inspector General of 
Hospitals and Fleets John Cassilis Birkmyre Maclean has 
been placed on the Retired List at his own request (dated 
Dec. 31st, 1907). 

The following promotions have been made : Deputy In¬ 
spector-General of Hospitals and Fleets William Edward 
Breton to be Inspector-General of Hospitals and Fleets in 
His Majesty's Fleet, and Fleet-Surgeon Frederick John Lilly 
to be Deputy Inspector General of Hospitals and Fleets in 
His Majesty's Fleet (dated Dec. 31st, 1907). 

The tollowing appointments are notified : Fleet Surgeon : 
H. F. Iliewicz to the President, additional, for three months’ 
course at the London and West London Hospitals. Staff 
Surgeon : M. Cameron to the Indefatigable, additional, and 
on recommissioning. Surgeon: J. N. Robertson, to the 
President , additional, for three months at West London 

Royal Army Medical Corps. 

Captain it. A. Bransbury lias been appointed to the London 
District. Captain A. C Outturn, from Agra, has been trans¬ 
ferred to the Burmah Division for dnty. 

Army Medical Reserve of Officers. 

Surgeon-Major Robert B. Graham to be Surgeon- 
Lieutenant Colonel (dated Dec. 17th, 1907). 

Royal Army Medical Corps (Volunteers). 

Eastern Command: Woolwich Companies: Lieutenant- 
Colonel and Honorary Colonel Francis Lawrence Stephenson, 
C.B., retired (lately Commanding), is appointed to the 
Honorary Colonelcy of the Companies, vioe Surgeon- 
Lieutenant-Colonel W. Collingridge, retired (late Militia 
Medical Staff Corps), who vacates that appointment (dated 
Oct. 16th, 1907). 

The Health of the United States Navy. 

The statistical report of the health of the Navy and 
Marine Corps for the year 1906 shows that the average 
strength of the active list during the year was 42 529, an 
increase of 1316 over the previous year, the average strength 
of 1905 being 41,313. The total number of admissions to 
hospital for all causes was 32,517, the ratio per 1000 of 
strength being 787 23. as compared with a ratio of 714 • 81 
for the previous year and 788 ’18 for the ten preceding years. 
There were 27,452 admissions for disease and 5065 for 
injuries, giving ratios of 658 47 and 121-49 respectively. 
The corresponding ratios for 1905 were 594-82 and 
106-67, from which it will be seen that the admissions 
for diseases and injuries were greater than in 1905. 
The number of persons invalided from the service during the 
year for disease and injury was 1117, giving a ratio of 26 26 
per 1000 of strength. The corresponding figures for the 
previous year were 1201 and 29'07 respectively. The ratio 
for 1906 is lower than that for last year and of the ten 
preceding years. The discharges for disability include 908 
for disease and 209 for injury, with ratios per 1000 of strength 
of 21 35 and 4 91 respectively. The corresponding figures 
for 1905 were 1023 and 4 • 38, with ratios per 1000 ot strength 
of 24 76 and 4 38 respectively. There were 241 deaths 
during the year, giving a ratio of 5 66, which is con¬ 
siderably less than that of the previous year (6 • 48) and 
less than the average of the ten preceding years (6 • 63). 
The diseases causing the largest number of admissions to the 
Bick list stand in the following order: gonorrheet, 2640; 
malarial diseases, 1854; tonsillitis, 1375; bronchial affec¬ 
tions, 1211 ; wounds, 1211; syphilis, 1147; epidemic 
catarrh, 1076; and rheumatio affections, 980. Venereal 
diseases caused a decided loss of efficiency, with 7273 
admissions, which is an increase of 1119 over the admissions 
for 1905 The admissions for these diseases show only 
approximately the prevalence of venereal infection in the 
navy, owing to the fact that a large number of cases of 
chancroid, and especially of gonorrhoea, are not admitted to 
the sick list, and hence are not included in the statistical 
reports. Venereal diseases give a total of 140,352 Bick days. 

The Lancet,] 


which is equal to the entire loss of the service of 384 men for 
the year. 

New Year Indian Honours. 

Major John Norman Macleod, I.M.S., Civil Surgeon at 
Quetta, has been made a Companion of the Most Eminent 
Order of the Indian Empire, and Major Robert Charles 
Macwatt, I M S , Residency Surgeon at Jodhpur. Rajputana. 
has been awarded for public service the Kaisar i-Hind Medal 
of the First Class. 


“Audi alteram partem.” 


To the Editor of The LANCET. 

Sir,— A service which Lord Kelvin rendered to publio 
health a few years ago perhaps deserves reference at a time 
when much is being written about his many activities. When 
it was decided to appoint a Royal Commission after the 
occurrence of poisoning on a large scale by arsenic in beer 
in Manchester in 1900 Lord Kelvin was asked bv Mr. Walter 
Long, then President of the Local Government Board, to be 
its chairman. The inquiry was certain to be—as it proved — 
lengthy and in several respects tedious. The subject, save 
that it called for ability to master a variety of com¬ 
plicated scientific and technical considerations, was far 
out of Lord Kelvin’s ordinary lines, and at the age of 
nearly 80 he might well have hesitated to burden him¬ 
self with it. But the request of the Government was 
sufficient; he acceded to the proposal, if I remember 
right, by return of post, and during 1901 and 1902 
he presided over nearly all of some 35 sittings (many of 
which occupied the greater part of a day) in London and 
Manchester. It is generally recognised that the work done 
by the Commission under his guidance has had valuable 
results. Its final report has become the recognised authority 
for the various manufacturing and brewing industries and 
also for the administrative bodies which are concerned with 
the question of arsenical poisoning through food, while its 
more general recommendations have had an important share 
in determining recent Government action to secure improved 
methods of coutrol in regard to impurities and deleterious 
substances in foodstuffs, as exemplified by Mr. Burns’s 
Kegnlations as to Food Act of last session. 

Many of those who were concerned with the work of the 
Commission will retain pleasant recollections of Lord Kelvin'B 
interest and active assistance and a vivid memory of the 
mental alertness and power of concentration which in him 
was so strong a characteristic. 

I am, Bir, yours faithfully, 

London. Dec. 21«t, 1907. G. S. BUCHANAN. 


To the Editor of The Lancet. 

Sib,—T he interesting communication of Dr. Hector 
Mackenzie on Mobility of the Kidneys which appeared in 
The Lancet of Oct. 26th, 1907, takes in all that is 
known on the subject, in my opinion. As regards the 
symptomatology, the statement of the author, when he 
says, referring to the greater part (411 in 515) of the cases 
which have come under his observation, that they ‘-had no 
symptoms which with any reasonableness could be attributed 
to the condition of the kidneys," expresses exactly the truth 
contained in the words of Professor Osier therein quoted, 
namely," that in the majority of the cases (‘in a vast majority,’ 
says Dr. Mackenzie) there are no symptoms whatever.” 

As a matter of fact, the epigastric pain mentioned by 
Edebobls as characteristic, the different manifest itions of 
dyspepsia, the vomiting crises described by Dietl, and the 
different neurotic affections, such as migraine, vertigo, 
leuralgia, hypochondriasis, epilepsy, neurasthenia, &c , have 
lot been established in cases of mobility of the kidneys 
vith the frequency necessary to prove clearly a connexion 
>et ween such phenomena and the anatomical derangement 

in question. Even a certain amount of irritability of the 
bladder with an irresistible desire to pass urine, which I have 
observed sometimes, and which is pointed out in Dr. 
Mackenzie s communication, I have been led to recognise 
by the further development of the case as a manifesta¬ 
tion of cirrhotic interstitial derangements of the gland 
concomitant with the relaxation of the organs which sustain 
it rather than being symptomatic of moveable kidney. 
The sensation of a lump in the lower part of the abdomen 
near the hip, so long as the nature of the tumour be not 
defined, is without any pathognomonic significance. 1 have 
seen patients who have complained that something is try¬ 
ing to escape from the belly through the groin when they 
run, cough, or lift htavy objects, and one was already wear¬ 
ing a truss when be came to consult me. 

It has been in such cases that I have been able to observe 
a symptom which I consider to be of real use in the dia¬ 
gnosis. It is the followirg. In persons habitually consti¬ 
pated, or who have to make great exertion at the time of 
defalcation, it happens that when they are emptying or 
beginning to empty the bladder they experience a sharp 
cruel pain which stops the flow of the urine and runs 
through the urinary passages with all the characteristics of 
nephritic colic. Instinctively the patient changes Ids position, 
rises from his seat, and puts his hand on the lower part of the 
belly, pressing or rubbii g the side affected ; by doing which 
the pain disappears with the same suddenness as that with 
which it came on, urination goes on, and everything proceeds 
in due course. The mechanism of the phenomenon seems to 
be explained either by a compression of the kidney caused 
by the effort to evacuate or by a sudden obstruction of the 
ureter by excessive twisting or distension and its r isappear- 
ance by the cessation of the circumstances mentioned, due 
to the movements of the patient. Having regard to an affec¬ 
tion which may easily pass unperceived from w»nt of sub¬ 
jective phenomena, I think that it is of use to point out any 
which, even occasionally, may serve to make it recognisable. 

On this understanding I have ventured to take up a small 
space in your columns, adding, in conclusion, that the pain 
to which I refer must have, in order to be regarded as a 
symptom of moveable kidney, the following feature : (1) a 
sudden appearance at the time of great exertion, chiefly 
during defecation and while the patient is passing urine ; 
(2) that the pain should be felt along the urinary passages as 
in nephritic co ic and with suffic ent intensity to interrupt 
urination ; and (3) instantaneous disappearance on change of 
position of the patient or light massage on the side of the 
abdomen affected. It is, of course, clearly understood that 
renal lithiasis may make itself felt in the act of defalcation, 
but the differentiation between such lithiasis and moveable 
kidney would be so easy that I do not think it necessary to 
point it out. I am. Sir, yours faithfully, 

Zacatecas, Mexico. JUAN BrKNA, M.D. 


To the Editor of The LANCET. 

Sir.—I have read with mnch interest the chairman's 
address to the Swansea division of the British Medical 
Association 1 but, while sympathising with Dr. J. Arnallt 
Jones’s desire to popularise the study of bacteriology 
amongst general practitioners, I venture to join issue with 
his opinion as to the role of the microscope in war. Dr Jones 
says that “Major Seaman of the U.S Army in his report 
pointed out that the Japanese medical offic er was invariably 
found in the first screen of scouts with his microscope and 
chemical reagents testing and labelling wells so that the 
army following should drink no contaminated water.” This 
might be accepted by an audience unacquainted with the 
conditions of military service but I do not think that the 
members of the medical department of any army will agree 
with the medical officer of health of Aberavon that it is “a 
brilliant practical illustration ” of “ what science can do in 
the way of preventing disease in war.” 

If Dr. Jones will refer to the Parkes Memorial Prize 
Essay for 1904 he will find that Lieutenant-Colonel Robert 
Caldwell, R.A M.C., who has had great experience, writes 
as follows : “ It does not appear likely that the introduction 
of a chemical laboratory into the field is likely to be fol¬ 
lowed by any particular benefit. An incomplete analysis is 
valueless ; it tells of danger but cannot tell of safety, and it 
iB impossible to carry out any analysis but an incomplete 

* Brit. Med. Jour., Dec. 21st, 1907, p. 1764. 

48 The Lancet,] 


[Jan. 4. 1908. 

one under the conditions of active service, and for this 
reason any such attempt should be abandoned. Water 
(water being naturally the main subject for analysis) 
might, for instance, give excellent results when examined 
chemically and might at the same time be swarmiDg with 
an extensive variety of disease producing germs. These 
latter could not possibly be detected without recourse to 
appropriate bacteriological methods and such methods could 
only liad practical application within the walls of a properly 
equipped laboratory.” a 

During the recent autumn manoeuvres in Wiltshire the 
writer of the foregoing, in his capacity as sanitary officer of 
the Northern Army, took samples of water from the River 
Wyley both before and after it bad passed through the new 
army water-cart. The samples reached the District Labora¬ 
tory, Devonport, the day following their despatch. I was 
in temporary charge of the laboratory during Colonel 
Caldwell’s absence and examined them for the presence of 
bacillus coli communis according to the method recorded by 
Dr. Thresh in his admirable work on “Water and Water- 
supplies ” (p 361). The river water gave unmistakeable evi¬ 
dence of bacillus coli in so low a dilution as one cubic centi¬ 
metre, whereas 20 cubic centimetres of the water which had 
passed through the service cart showed no evidence of coli- 
form organisms. The chemi ai constituents of both samples 
were within the limit prescribed for “a good potable water." 
This bears out Colonel Caldwell’s opinion, as expressed above, 
that incomplete or chemical examinations of water are value¬ 
less and shows, I think, that if the Japanese medical officer 
was actually “ with the first screen of scouts analysing water 
and labelling wells ” his labours were sad waste of energy 
and his ‘ labels ” not worth the paper they were written on. 

In conclusion, I venture to predict that the microscope 
will perform an important idle in the wars that are to oome 
but it will be neither “ with the first line of scouts " nor in 
the stress of the fighting line, but in the properly equipped 
laboratories which the sanitaiy section of the expeditionary 
forces of the future will establish at their base and on their 
lines of communication. 

I am, Sir, yours faithfully, 

R J. Blackham, 

Devonport, Dec. 23rd, 1907. Major, Royal Army Medical Corps. 


To the Editor of The Lancet. 

Sir,—I n the large mass of recent literature on the subject 
of tbe most satisfactory method of draining the bladder after 
snprapnbio cystotomy the simplest and best method of all, 
by what may be called natural syphon action, appears to 
have been temporarily forgotten. The method 1 have been 
in the habit of ui-iDg in such cases for some time past has 
the merit of simplicity and efficiency and is briefly as follows. 
The incision in the bladder wall is reduced in size by a series 
of strong catgut sutures, introduced on the Lembert principle, 
until only a sufficient opening is left to take a large drainage- 
tube. Two boles are cut on opposite sides of the lower end of 
this tube which is placed well down on to tbe trigone or into 
the cavity from which a prostate has been removed. The 
long end projects from the wound and the tube is fixed in the 
opening in tbe anterior wall of the bladder by a purse-striog 
catgut suture, one portion of which transfixes the tube to 
still further secure it in position. The skin inci-ion is left 
widely open and the connective tissue space around the 
bladder, which has been opened up in the course of the 
operation, is carefully but lightly packed with sterilised 
gauze. When the patient has been put back to bed a long 
narrower rubber tube is attached to the tube in the bladder, 
and then runs over the side of the bed into a bottle or ot> er 
vessel containing dilute lysol solution, the end of the tube 
naturally beiDg below the level of the fluid. The syphon 
thus formed starts to work of itself and in my experience 
answers admirably. It is important to take care that the 
purse-string suture produces a good funnel-shaped pro¬ 
jection of bladder wall round tbe tube and to test the 
efficacy of the closure of the bladder by distending 
the cavity with fluid, passed into the bladder by means 
of a soft catheter by the urethra, before the operation 
is completed. The bladder may be washed out in the 

2 Prevention of Disease in Armies in the Field, p. 149. 

same way after the operation if necessary, bnt usually 
tbe drainage is so perfect that it is only in advanced cases of 
bilharziosis, or cystitis from any other cause, that this will 
be required. The tube is left in from four to eight days and 
on its removal the bladder is washed out from time to time by 
the urethra. A few days later the bladder has dropped back 
well into its place and the wound in it is firmly healed. It 
is a great mistake, in my opinion, to attempt to suture tbe 
bladder wall to the skiu or deeper tissues, as this procedure 
is so often followed by a very intractable sinus. Once the 
tube has been removed the patient should be allowed to sit 
up and two days later to walk, as both these actions tend 
to drive the urine, so to speak, out of the bladder by its 
natural channel. The rather special opportunities one has 
in the practice of bladder surgery in Egypt must be my 
apology for venturing to trespass on your space to this 
extent and the feeling that, perfect as some of the more 
complicated methods appear to be, they are rather un¬ 
necessary in view of the simpler measures which are at our 
disposal. I am. Sir, yours faithfully, 

Cairo, Deo. 3rd, 1907. FRANK C. MaDDEN. 


To the Editor of The Lancet. 

Sir,—T he interesting communications under this title 
have drawn attention to a condition which, though familiar, 
is not often described. It should, however, be kept distinct 
from acute suffocative catarrh, a condition well described by 
Laennec, but not, it would seem, generally recognised now 
any more than it was at the time he wrote. To the description 
Laennec gave, little, if anything, can be added. Dyspncea 
comes on suddenly, rapidly becomes intense, and in a few 
hours the patient may die from suffocation. If life be pro¬ 
longed the condition becomes one of ordinary bronchial 
catarrh. Laennec’s suffocative catarrh has to be distinguished 
from capillary bronchitis and disseminated post-bron- 
chitic broncho pneumonia, for in these cases the suffo¬ 
cative symptoms are secondary. More closely resembling 
it are primary broncho pneumonia—i.e., disseminated 
pneumococcal broncho pneumonia and possibly an acute 
pneumococcal or other bacterial bronchitis In associa¬ 
tion with it may be placed : 1. Cases of acute pulmonary 
oedema which develop in the course of chronic heart 
obstruction or of acute heart failure, such as most of those 
are which have been recently described. 2. Cases of col¬ 
lateral fluxion or pulmonary failure such as are familiar in the 
course of acute pneumonia in tbe non-coneolidative parts of 
the lung. 3. An interesting but not common group of cases 
in which acute pneumonia commences with widespread pul¬ 
monary congestion, the general congestion disappearing as 
the local lesion develops. 

I write this as a preliminary note, for I propose to.briog 
the whole subject shortly before one of the medical societies. 
It has been stated that no account of these conditions appears 
in the ordinary text books. The various conditions I have 
referred to are, however, all discussed in my book on 
“Diseases of the Respiratory Organs,” and I daresay else¬ 
where too. I am, Sir, yours faithfully, 

Dec. 30th, 1907. _ Samuel West. 

To the Editor of The Lancet. 

Sir. —Tbe clear clinical picture of “Acute Pulmonary 
(Elema.” drawn by Dr. Leonard Williams in The Lancet 
of Dec. 7th, 1907 has left an impression on my mind which 
will never be effaced. Although the condition is one of 
great rarity, doubtless its occurrence is much more frequent 
than is generally supposed, being overlooked by the fact 
that no description of it is to be found in any of 
our English text-books, and hence students have not 
been made familiar with the symptoms. I can cer¬ 
tainly recall a case in which, although a fatal issue was 
not unlooked for, I was yet unable to account for the long 
stream of foam issning from the month and nose, and have 
now no doubt that tbe actual cause of death was acute 
oedema of the lungs. The omission of such an important 
mode of death from our English text-books, and also I notice 
from the 1 Nomenclature of Diseases” issued by the Royal 
College of Physicians of London, is much to be regretted, and 
one can only hope that it will be repaired at an early date. 

I am, 8ir, yonrs faithfully, 

Alexander Bryce, M D. Glasg., D.P.H. Cantab. 

Moseley, Birmingham, Dec. 26th, 1907. 

The Lancet,] 



To the Editor of Thb Lancet. 

Sir,—I n commenting on the report of a meeting recently 
convened by the Association for Promoting the Training and 
Supply of llidwives, the Times in a leading article expressed 
regret that none of the speakers, beyond urging the necessity 
for increased support of the Association, gave any indication 
as to the means by which the serious difficulty is to be met 
which may arise in 1910 when the clauses in the Act 
forbidding the practice of midwifery by unqualified persons 
come into operation. The opinion was also expressed that 
"a very definite organisation with definite and clearly stated 
aims is a necessary condition of any extended support from 
the public.” A subsequent letter from the Council of the 
Association makes the issue clear—viz., which is to come 
first, the plan or the money i 

1 am writing in the hope that the suggestions contained 
in this letter may help the Association to a decision upon 
this point. I cannot claim to speak with any authority on 
the general question, but I have been led during the past two 
years to take an interest in it owing to my appointment as 
a visitor of some of the lying-in hospitals of London by the 
Conncil of King Edward’s Hospital Fund. No one can enter 
the wards of one of these hospitals without being struck 
with the enormous advantage which any poor woman whose 
labour is conducted there enjoyB over her less fortunate 
Bister who is confined in her own home, often amidst 
surroundings which can only be realised by those who have 
actually witnessed them. It is gratifying to learn that by 
the adoption of a rigidly aseptic and antiseptic method 
maternal mortality has in these institutions been practically 
abolished. It is equally saddening to reflect that whilst the 
lying-in ward has been transformed from a death-trap to a 
place of the greatest attainable safety, there has been little 
or no diminution in the mortality from child-birth through¬ 
out the country generally. 

The Faculty of Medicine of the University of London was 
recently asked by the Senate to advise as to the action to 
be taken by the University upon the proposed regulation of 
the General Medical Council that every student shall be re¬ 
quired to have received instruction and gained his practical 
knowledge of midwifery by attending the requisite number 
of labours, either in a lying-in hospital or in the lying-in 
ward of a general hospital. I am glad to say that a resolu¬ 
tion was passed that in the opinion of those present “ teach¬ 
ing in practical midwifery in the wards of a lying-in hospital 
or in the lying-in ward of a general hospital should be made 
compulsory as soon as practicable." 

I lately suggested to the Weekly Board of the Middlesex 
Hospital that a lying-in ward should be established, so that 
our students may learn this most important branch of their 
profession under the best possible conditions and not, as 
hitherto, by attendance upon the poor living in the area 
supplied by the hospital. The suggestion received the 
approval of the board and of the medical staff and a 
committee is about to report upon the changes necessary 
to carry it into effect. The existence of such a ward is no 
new thing, as in 1747 it was enacted that “a third part of 
the beds used in the hospital from time to time be appro¬ 
priated to the use of lying-in women.” The total number of 
beds in the hospital at that date was either 18 or 22. In 1749 
a rule was established that “ whenever there shall be an 
increase of beds for sick and lame the same number be also 
added for lying-in women.” In 1783, owing to lack of funds, 
retrenchments became necessary and these were continued at 
intervals until 1807, when the lying-in ward was abolished. 

Such a ward in a general hospital to which a medical 
icbool is attached would serve a fourfold purpose: 1. It 
would insure that a certain number of poor women were 
ielivered under conditions involving in a normal pregnancy 
he minimum risk to life. 2. The offspring would be free 
rom the danger of contracting purulent ophthalmia, which 
wo of the speakers at the meeting referred to stated to be 
re cause of fully one-fourth of the cases of blindness in the 
immunity to-day. 3. It would afford the students an 
-iportunity of learning thoroughly the aseptic and antiseptic 
chnique of modern midwifery, knowledge which must in 
leir future practice be of the greatest service to them and 
erefore to the public. 4. It would allow the hospital to 
come a. centre for the training of nurses skilled and 
rti floated in midwifery and thus increase its claims to 

public support. Some of these nurses might be available for 
attendance upon the poor living in the neighbourhood of 
the hospital, thus replacing the services of the students. 

I would therefore suggest to the Association that it should 
forthwith institute a campaign throughout the country to 
urge: 1. That every general hospital should as soon as 
possible provide a lying-in ward. 2. That the general 
hospitals in each county should become centres for the 
instruction of midwives, who would obtain there the 
certificates necessary to secure admission to the Roll. 
3. That one or more branches of the association should be 
established in each county in connexion with the general 
hospitals in order to ascertain and provide for the wants of 
the county as regards midwives and to organise and to super¬ 
vise their work. 4. That the county councils and local 
authorities should exercise the powers given to them by the 
Act of making grants towards the cost of the education 
given to midwives in the hospitals; thus the whole community 
would bear a part of the expense to which the hospitals 
would be put in carrying this proposal into effect and not only 
those members of it who recognise their duties to the poor. 

I venture to submit these suggestions as the basis of a 
scheme which may provide “ the definite organisation with 
clearly stated aims” necessary to secure increased public 
support of the Association. I have not referred to the good 
work which I know Queen Charlotte’s Lying in Hospital is 
doing in increasing the provision for the instruction of 
students, as the need is for a scheme applicable to the 
country as a whole. 

I am, Sir, yours faithfully, 

J. K. Fowler, 

Dean of the Faculty of Medicine, University of London. 

Clarges-street, W., Dec. 28th, 1907. 


To the Editor of Thb Lancet. 

Sir, —The statements made with reference to the 
coefficient of various disinfectants against the bacillus 
pestis indicate that this organism is particularly susceptible 
to the influence of the various preparations used for 
disinfecting purposes, but I gravely doubt whether all these 
statements are absolutely reliable. My reason for saying 
this is based upon the results of a series of experi¬ 
ments made when examining a well-known disinfectant. 
I found that using broth for cultivating purposes, with 
and without the addition of a little butter, the results 
were sometimes doubtful. I therefore made from all the 
tubes giving no definite indications of growth agar slope 
cultures and was not surprised to find after several days that 
a distinct growth of the bacillus pestis made its appearance. 
The result was that the disinfectant under trial gave a 
coefficient about the same as that obtained when the bacillus 
typhosus was used, whereas judging from the broth cultures 
alone it was nearly twice as high. An attempt was made to 
use agar slopes in the first instance instead of the broth, but 
the results then differed widely from those obtained either 
with broth alone or with broth followed by agar. Probably 
other bacteriologists interested in this subject may care to 
repeat my experiments and confirm or disprove my results. 
This is my excuse for troubling you with this letter. 

I am. Sir, yours faithfully, 

John C. Thresh. M.D. Viet., Ac. 

London Hospital Medical College, Dec. 23rd, 1907. 


To the Editor of The Lancet. 

Sir, —At Stoke Newington recently inquests were held 
upon the bodies of twin boys, aged 18 months, who were 
found dead at the same time in the same bed on a Friday 
afternoon about 6 P.M. One child had been brought up by 
the bottle on cow’s milk and barley water and the other had 
been suckled. Both had seemed well until the Sunday 
before, when both became poorly with colds in the head and 
coughs. The mother treated the children with castor-oil and 
embrocations of camphorated oil. She did not think either 
was seriously ill until the Friday, when one was taken to a 
doctor who prescribed for it at noon; the other had no 
medical attendance. The parents declared that both had 


[Jan. 4, 1908. 

been seen alive by them about 5.30 P.H. ; half an hour after 
both were dead, lying on their sides, faces not covered up, 
some distance apart Post-mortem examinations showed a 
similar state of broncho pneumonia; there were no injuries 
and no suspicion of foul play. 

I am. Sir, yours faithfully. 

W. W. Westcott, 

Dec. 28th, 1907. Coroner. 


To the Editor of The Lancet. 

Sib, —I notice in The Lancet of Dec. 21st. 1907, p. 1778, 
that a reference is made to the adoption of new regulations 
by the Hailsham rural district council under the Dairies, 
Cowsheds, and Milksbops Orders 1885, 1836, and 1899. In 
the same article you imply that the Hailsham council has 
had no Dairy, Cowshed, and Milkshnp Regulations for the 
past 20 years. You have evidently been misinformed. Asa 
fact the Hailsham rural district council was one of the 
first councils to make regulations under the Dairies, 
Cowsheds, and Milkshops Orders 1885, 1886, and the old 
regulations were more strict than the new regulations. 
The Hailsham council, acting on the advice of its medical 
officer of health, has recently brought the above regulations 
up to date and these remodelled regulations will come into 
force on Jan. 1st, 1908 It is no doubt these revised regula¬ 
tions that your correspondent has mistaken for the Order. 
I would point out that the Dairies, Cowsheds, and, Milkshops 
Order is not adoptive as described in your article under 
London’s Milk-supply. 

I would also draw your attention to the fact that the Order 
does not compel local authorities to make regulations, 
but, unfortunately, merely empowers them to do so, and 
the Legislature should doubtless have made the making 
regulations under the Order compulsory instead of permissive. 
It is a matter for deep regret that your usually accurate 
journal should be blemished by a contribution the author 
of which shows want of knowledge, both as to his legal 
principles and facts. 

I am, Sir, your obedient servant, 

Hugh Stott, 

Medical Officer of Health, Hast Sussex Combined 

Dec. 26th, 1907. Sanitary District. 

*** We are sorry to find that our correspondent has made 
a mistake.—E d. L. 


To the Editor of The Lancet. 

Sib,—P erhaps it may interest a few of your readers to 
know how the licence to practise medicine in the Turkish 
Empire is to be obtained. Perhaps this licence is not 
absolutely necessary for an English practitioner whose work 
lies solely in an English institution, yet it is strongly recom¬ 
mended to be obtained as without it one has no legal right to 

First from the Consulate (fee 10s.), or from some friend 
who can write a formal Turkish letter, a “ petition ” is 
obtained stating that X, a British subject, graduate of 
such a University, desires the licence of the Ottoman 
Government. This letter addressed to the Director-General of 
Medical Affairs (Nazir Mekteb Tibbiye SI aha' e) you take to 
the Haidar Pasha new military medical school near Skutari, 
to a room called evraq odasy. There a clerk gives you a form 
bearing a number (fee 20 paras = Id.), and you are 
probably told to call in a week’s time. Meanwhile, the 
petition goes before some authority and on your next visit 
you pay in an adjoining office (Bureau de Comptabilitf) 
£T 20 + 20 paras ; no receipt is given yet. Five days later, 
probably, on visiting the original office and displaying the 
number, the clerk, turning up his register, writes “council” 
on your form, and after waiting an hour or so you enter to 
see the council which examines your university diploma and 
medioal registration certificate The former it retains, all 
things being satisfactory, and you enter an adjoining room for 
a v'va-voee examination by the professor of anatomy, of 
surgery, and of medicine. This examination is a perfectly 
fair gentlemanly one. If you display a reasonable know¬ 
ledge of your profession you are immediately afterwards 
invited to the council room where the chairman declares 
your acceptance. 

The examination must be taken in French or Turkish. An 
interpreter is allowable. Then comes a wait of some ten 

days during which your diploma and the result of the test. 
Sec., pass to the Director-General and are finally returned to 
the school. It is necessary in the meantime to pay a visit to 
the Sublime Porte to have your passport legalised (fee half 
Turkish pound 4- 2 piastres). The return of your papers 
is announced in Turkish on a notice board in the ball in 
which you do so much waiting. Your university diploma is 
now returned to you and also a receipt for the fee, and after 
a period varying according to whether there are others 
ready with you or not, you are led before the Director- 
General to swear the oath not to procure abortion, 
not to treat hardly the poor, to call your professional 
brethren in consultation when necessary, &c., aDd after paying 
21 piastres (3s. 6 d.) for a stamp, your licence is handed to 
you. The examination and council, kc., are held three 
times weekly—Mondays, Thursdays, and Saturdays, and it 
is advisable to call regularly on each of these days when 
waiting, as the clerk’s instruction to come in a week's time 
is but a way of speaking. In the first office and the fee¬ 
paying office there is no one who speaks French. The whole 
affair takes three weeks if very fortunate, five weeks usually, 
and seven weeks if unfortunate. In Egypt the same affair 
takes from four to five days and there is no examination 
and a nominal fee of 3>. 6 d. or so to pay. 

I am. Sir, yours faithfully, 

Baghdad. P. A. H. RADCLIFFE, M.B. Viet., D.T.M. 


To the Editor of The Lancet. 

Sir,—I n a letter in The Lancet of Dec. 2lst, 1907, p. 1785, 
Dr. Amand Ronth says, “ I cannot recall any acute sentic 
condition of the endometrium where curettage with a sharp 
curette has done good.” I should like to bring forward 
some statistical evidence on this point. In the Journal of 
Obstetrics for January, 1907, in a paper dealing with 
the treatment of puerperal sepsis, I wrote: “Out of 79 
cases (of my own) treated by general means, with or without 
intra-uterine douches, 37 died—a mortality of 46 per 
cent. In 86 cases where the method I have described 
was employed the mortality was 23 per cent, only.” I can 
now add to the latter serits 43 more cases with 11 deaths. 
The method referred to consists in the removal of the endo¬ 
metrium as completely as possible with a large sharp curette 
followed by swabbing of the resulting raw surface with 
undiluted izal. I should add that all the patients were 
intensely ill when I first saw them and that the large 
majority had been treated previously by intra-uterine and 
vaginal douches for several days, the average day of admis¬ 
sion to hospital being, in fact, the fifth of the pyrexial 
period or, in other words, the stage which is certainly not 
the most favourable for the use of the Bharp curette. I do 
not see mild or early cases at all. 

I am well aware of the fallacies which attend the use of 
the statistical method in such a complex disease as puerperal 
sepsis, but I think it is evident that these figures do not 
justify the inference that the use of the sharp curette is per 
se either dangerous or inadvisable and that the number of 
cases, 208 in all, is sufficiently great to be worth quoting in 
this connexion. I am, Sir, yours faithfully, 

A. Knyvbtt Gordon. 

Monsall Hospital, Newton Heath, Manchester, Dec. 22nd, 19-7. 


To the Editor of The Lancet. 

Sir, —The town council here has adopted the above Act 
and I shall be compelled under a penalty to notify all my 
confinement cases without receiving any compensation 
therefor, which is not quite just. However, the spirit of the 
Act is a step in the right direction and one must not com¬ 
plain. It seems a pity that the scope of the Act did not 
enable the local authorities to take an interest in both the 
mother and the child at parturition. Obstetricians who have 
the true spirit of their office must have felt unhappy and 
uncomfortable after refusing to get out of bed to attend a 
woman in labour who had been so improvident as not to have 
engaged anyone to attend her, knowing well from past 
experience that the only recompense that these improvident 
people afford is the approving conscience of haying 
done your duty, which is very satisfying at the time, 
but of no avail in paying the bills of the butcher. 

The Lancet,] 


[Jan. a, 1908. 51 

the biker, the dressmaker, the draper, the landlord, 
the tailor, and other tradesmen. The objects of the 
Act would have been more tally accomplished had it 
empowered local authorities to grant a moderate fee to any 
licensed practitioner who attended a case of confinement 
in circumstances precluding any hope of any other re¬ 
compense. The present Government seems inclined to pass 
enactments to ameliorate the condition of the masses, and 
if any of its measures would make it impossible for anyone 
to spend in drinking, betting, and smoking the money that 
should be spent in supplying himself or herself and 
dependents with the necessaries of life the above Act and 
many others would never have been required. Until restric¬ 
tions are put on these three bad habits, so that no one could 
spend more than a certain amount on either of them—the 
amount allowed to be limited to income and obligations— 
all other ameliorative measures will be comparatively useless. 
Slavery has been abolished in the British dominions, but there 
are still a great many people who would be better to be still 
in slavery under a kind master. They are quite unworthy 
of their freedom and cannot enjoy it properly, and if the 
present Government passes rest icti e measures to prevent 
these unworthy people from injuring them elves, thdr de¬ 
pendents, or the community generally, then others who need 
no such restrictions should cheerfully acquiesce in the new 
arrangements for the sake of their we iker brethren. It is 
hoped and expected that Parliament, so >n to as emble, will 
put restrictions on these three great evils. 

I am, Sir. yours faithfully, 

John B. Hunter, M.D., O.M. Glisg. 

Paisley, Dec. 28th, 1907. 

PS.—It is certainly an outrage on humanity and a dis¬ 
grace to civilisation that a poor woman in labour cannot 
command skilful attention in her dire distress. 


To the Editor of The Lancet. 

Sir,—I should be much obliged if your readers in other 
parts of the country would favour the medical profession 
with information as to bow their county councils are going to 
carry out the medical inspection of school children. Are 
they going to appoint whole-time medical inspectors specially 
for this purpose or are they going to intrust the work to be 
done to general practitioners ? It appears to me that the 
claims of tbe latter are being overlooked in the matter and 
that the county councils, in appointing a special staff wholly 
for this work, are embarking on an expensive method. The 
inspection is one which, in my opinion, will require great tact, 
and in this the knowledge of the local practitioner would be 
invaluable. I am, Sir, yours faithfully, 



To the Editor of Tils LANCET. 

Sir,—W ill you permit an old correspondent whose first 
contribution appeared in your pages more than 50 years ago 
to make a personal explanation ? A few weeks ago, in 
sorting some papers that had accumulated, I came across a 
circular or report from the Autivaocinatlon Society. Glancing 
over it I saw a list of correspondents of the society in foreign 
parts. To my extreme disgust l found my own name pub¬ 
lished as the Hew Zealand (or Auckland) correspondent. My 
only correspondence with the society during the 34 years I 
have been in this colony was to answer an application from 
the secretary, who asked me whether I would allow extracts 
from a paper on Compulsory Vaccination which I had read 
here before our branch of the N Z. Institute to be published 
by the society. My reply was that they might reprint the 
whole paper (which was not a long one) if they liked, but 
that I would not allow extracts to be made. I have never 
had a reply to this. My object in refusing to allow extracts 
was that I knew they would pick out certain cases of vaccino- 
syphilis which I had seen in the days of arm-to-arm vaccina¬ 
tion, and not reprint the statement I made that no one who 
had seen a bad case of confluent small-pox would hesitate 
about preferring the risks attendant on vaccination to the 
risks of incurring such a disease as small pox. But as 
small-pox has never been epidemic here I see no necessity 
for enforcing vaccination. 

I may mention teat as physician of the small-pox hospital 
in Port of Spain, Trinidad, during the epidemic of 1871-72, 
I saw two cases of confluent small pox both of whom had had 
confl uent small-pox before in the severe epidemic. One I had 
had under my own care, the other one was seen in the 
ho spital by the medical man who had attended him in the 
fi rst attack. These ca tes are given in my little work on “The 
Pathology and Treatment of Small pox," published in 1872. 
I have had to bear a good deal of odium on account of my 
opposition to compulsory vaccination, and some people have 
treated me as a heretic about vaccination. I am perfectly 
orthodox on tbe subject and always have been, 

I am, Sir, yours faithfully, 

R. H. Bakswbll, M I). St. And., 
Surgeon-Captain (retired) Army Medical Staff. 

Auckland, N.Z., Nov. 10th, 1907. 


To the Editor of The Lanobt. 

Sir —The answers to the questions put by “ J. S.” in The 
Lancet, of Dec. 21st, 1937, p. 1793, seem to me to be as 

1. The education authorities have power compulsorily to 
acquire sites for their hospitals, because the provision of 
these hospital and vacation school sites. Ate., is by Section 13 
of the Education (Administration Provisions) Act, 1907, in¬ 
cluded in the powers and duties of a local education 
a«t lority under Part III. of the Education Act, 1902. For 
the pirposes of Part lit. of the Act of 1902 land may be 
taken in one of three ways : (a) by agreement under the 
agreement sections of the Lands Clauses Oonsolidation Acts, 
which Acts are expresslv incorporated in the Elementary 
Education Act, 1870, o. 75. s. 20 (1) (unrepealed) ; (J) under 
the School Sites Acts (Elementary Education Act, 1870, 
c. 75, s. 20, last clauses unrepealed); (c) "Otherwise than 
by agreement,” that is, compnlsorily under the Land Clauses 
Consolidation Acts. 

2. With regarl to the question of employing qualified 
medical practitioners I think that the education authority 
can employ any snitable person, whether a qualified medical 
practitioner or not. There is no provision in the Act. 
Section 136 of the Public Health Act, 1875, gives the local 
authority power in cases of any formidable epidemic disease 
to “appoint and pay suoh medical or other officers or persons 
and do and pro ride all such matters and things as may be 
necessary for mitigating such disease, ot for superintending 
or aiding in the execution of such regulations.” Although 
that section only applies in case of a formidable epidemic, 
yet we may draw the inference that as the local education 
authority has authority to establish hospitals it has the 
power to appoint any qualified nurses, or, in fact, any 
suitable pe> son to look after them. Id the case of a small¬ 
pox hospital the Local Government Board has not objected 
to the medical officer of health acting as medical super¬ 
intendent, but it considers, in view of the duties which he 
has to perform as medical officer of health, that it would be 
undesirable that he should reside in the hospital. 

3. I thiDk that the treatment need not be free, for the 
education authority has power under tbe Elementary Educa¬ 
tion Act, 1870, c. 75, s. 3 (still nnrepealed), to charge pupils 
fer education in their elementary schools any sum not exceed¬ 
ing ninepence per week per scholar, consequently the authority 
would Beem to have the power of charging for medical 
attendances when the parents are capable of paying. 

4 The authority does not appear to have the power to 
admit to eneb hospitals the children of ratepayers who do 
not send their children to the elementary schools, for Section 
13 specially mentions children attending elementary schools. 

5. I think that the local education authority may, with the 
approval of the Board of Education, supply free of charge 
spectacles and surgical appliances under s 13, subs. 1 (J) of 
the Act of 1907. I think that the words, “the power to 
make such arrangements as may be sanctioned by the Board 
of Education for attending to the health and physical condi¬ 
tion,” confer such power. 

6. I am of opinion that the authority can decide that the 
child requires spectacles and that the parent can afford to 
pay for them, and if the child comes to school without 
spectacles the authority can refuse it admission and prosecute 
the parent for not sending it to school, as such a rule would 

52 Thh Lancet,] 


[Jan. 4,1908. 

be reasonable. (See the case of a verminous child in 
The Lancet, Nov. 9th, 1907, p. 1342.) 

I am, Sir, yours faithfully, 

Dec. 28th, 1907. A LAWYER. 


1o the Editor of THE LANCET. 

SIR,— In the controversy now proceeding with regard to 
the allied, but by no means identical, subjects of the title of 
'• Dr.” and degrees for London students of medicine it is as 
well to endeavour not to confuse the real issues. There is, 
on the one hand, a demand that the degree of "M.D.” 
should be in some way brought within the reach of all those 
who are of average mental capacity and have studied medi¬ 
cine sufficiently to pass a qualifying examination. There is, 
on the other hand, the demand that all those who have 
passed any qualifying examination should be entitled to 
assume the prefix of "Dr.” With regard to the former, 
what we desire to know is. What are the impediments which 
prevent all London medical students from matriculating at 
the University of London 1 When these are clearly set out 
it will be easy to consider what modifications can bene¬ 
ficially be made in the existing regulations. The second 
demand is quite on a different footing. It seems that 
the public has made up its mind that a university 
education is of advantage in a doctor and prefers 
to go to those who have obtained the stamp of 
"M D.” Those who have not obtained this stamp there¬ 
fore declare that they are at a disadvantage and that they 
must be allowed to pretend that they have obtained the 
coveted stamp by placing the title “ Dr.” before their 
names. This appears to be a distinctly dishonest expedient, 
and the dishonesty is not lessened by the fact that the word 
“doctor ” is the recognised popular term for a medical man. 
A solicitor does not put on his brass plate "Solicitor J. 
Jones,” but “Mr. J. Jones, Solicitor.” There would 
presumably be no objection to a doctor who was not a 
member of a university similarly putting " Mr. E. Smith, 
Doctor.” I venture, however, to prophesy that this 
would not satisfy the claimants for the title “Dr.” Yet if 
it does not, it seems clear that what they desire is not to be 
known as doctors but to be falsely reputed to have obtained 
a university degree. While, therefore, there is every reason 
to endeavour to facilitate the entrance of students of 
medicine at the London and other universities, there is none 
for altering the present arrangements by which the M.D. 
degree is obtainable only by members of a recognised uni¬ 
versity. Nor does there seem any reason to complain that 
London has but one university, so long as that university 
embraces many constituent schools scattered over the metro¬ 
politan area, at which there is plenty of room for medical 
students. I >">, Sir, yours faithfully, 

Dec. 29th, 1907. _ VERAX. 

To the Editor of The Lancet. 

g 1B _Year after year one reads in the columns of 

The Lancet letters from discontented individuals who wish 
to get an M.D. degree without working for it. The care is 
always the same: Mr. Smith, M.R C.S. or L.S.A., is ashamed 
of his qualifications and jealous of his neighbour Dr. Jones 
who has gone through a much more advanced course of 
study and obtained the degree of Doctor of Medicine. The 
arguments adduced by the advocates of the " M.D. England ” 
and repeated with such monotonous regularity are decidedly 
amusing and would make interesting reading did not their 
frequent distortion of facts and wilful misrepresentations 
remind one rather too forcibly of the antivivisectionist 

literature. , 

However, there are two real gems in your issue of 
Dec. 21st. The first is a letter signed by “ Have Not,” in 
which we find the brilliant suggestion that the University of 
London might “institute a degree for Conjoint men of 
mature age much on the lines of that of St. Andrews.” 
Apart from the incongruity of the whole thing, there is 
something inexpressibly quaint in the very idea of venerable 
practitioners of 15 or 20 years’ standing flocking on a 
pleasant picnic to South Kensington and returning home 
with an M.D. degree in their pockets. “Sympathiser" 
supplies the second in seriously proposing a revival of the 
ancient custom of the granting of the M.D. Lambeth by the 

Archbishop of Canterbury. One can almost imagine the 
learned Primate of all England, suitably robed for the 
occasion, personally conducting a vivA vooe examination in 
medicine with the aid of the most recent edition of the 
“Family Physician.” But seriously, such retrogressive 
steps as suggested in these two letters would simply be an 
absurdity to the intelligent, and demoralising by their 
conscious support of falsehood and fraud. 

I am, Sir, yours faithfully, 

Kensington, Dec. 24th, 1907. M.D., M.R.O.S., L.R.C.P. 


(From the British Delecate on the Const antinopie 
Board op Health.) 

The outbreak of cholera in Russia is now subsiding. It 
has not been a eevere one in comparison with many that 
have occurred there in the past. It has, nevertheless, 
carried off a not inconsiderable number of victims. The 
total number of cases officially reported since the beginning 
of the epidemic on July 3rd down to Nov. 6th 1 is placed at 
11,472 and that of deaths at 5493. The official returns for 
the six weeks preceding the date just named are set forth in 
the accompanying table. The figures therein contained are in 
continuation of those published in my preceding letters.- 

The weekly totals, as given in the last line of the table, 
are those officially returned by the Russian Government; it 
will be observed that they are incomplete and do not quite 
coincide with the sums of the individual figures in their 
respective columns. It is probable that all the figures must 
be regarded as aporoximative only. In European Russia the 
towns and governments along the valley of the A olga have 
been among the worst sufferers from the epidemic, hut the 
town of Kief has also been the scene of a serious outbreak. In 
Asiatic Russia the government of Tomsk and the Akmolinsk 
territory have been the most severely affected, and it cannot 
escape remark that nearly all the governments and provinces 
of Siberia, including the Transbaikal territory, have been 
invaded by the disease. 

The outbreak of cholera on Turkish territory, on the road 
between Kars and Erzeronm. reported in my last letter, 
seems to have subsided rapidly. Later information states 
that there were two groups of Russian emigrants, botti from 
the Caucasian province of Daghestan. The first, of 94 
persons, reached the Russo-Turkish frontier post of Keutekon 
Oct. 22od and left on the next day ; the second arrived there 
on the 24th and left on the 26th. Most of the cases appear 
to have occurred in the second group. Only villages on the 
line of march of these emigrants were affected by the 

A death from cholera recently occurred in Constantinople. 
The deceased man was one of a group of Mongolian pilgrims 
on their way to the Hedjaz. This group had come from 
some portion of the Chinese Empire, by way of Tashkent and 
Odessa. It had taken them 45 days to reach Tashkent; 
thence they travelled by rail, arriving in Odessa in five days; 
they Btayed a day or two there, took ship to Sinope, where 
they underwent five days’ quarantine and the disinfection of 
their clothes and effects. It may be added that they sailed 
from Odessa on Nov. 5th (New Style), reached Sinope on the 
7th, left there on the 12th, and arrived in Constantinople on 
the 13th. It was only in the night of the 14-15th that the 
symptoms of cholera appeared in one of them ; he died 24 
hours later. A bacteriological examination was made and 
a bacillus was isolated possessing almost all the characters of 
Koch’s comma vibrio ; the points in which it differed from 
the latter were that it coagulated milk and did not give the 
cholera red reaction. The case was treated in all respects as 
one of cholera ; the large khan in a densely crowded quarter 
of Stamboul where it occurred was evacuated, all the other 
pilgrims of the same group were removed to the lazaret at 
Kavak, at the northern entrance of the Bosphorus, where 
they did 15 days’ quarantine, the klian was disinfected, and 
other precautions were taken. A second case of illness 
occurred in the group, but clinically, pathologically, and 

1 Where not otherwise stated the dates mentioned in connexion with 
ho epidemic In Russia are all according to the Old Style, both in the 

ext and in the table. _ , inn ,, -ic-m 

2 The Lancet, Oct. 19th (p. 1119) and Nov. 30th 1907 (p. 1571)- 

The Lancet,] 


[Jan. 4, 1908. 53 





Sept. 26th to 
Oct. 2nd. 


i Oct. 3rd to 
j Oct. 9th. 


Oct. 10th to 
Oct. 16th. 


Oct. 17th to 
Oct. 23rd. 


Oct. 24th to 
.Oct. 30tb. 


Oct. 31st to 
Nov. 6th. 

j Totals from be¬ 
ginning of epi¬ 
demic (July 3rd) 
to Nov. 6th. 


European Russia. 



Cases. Deaths 



Cases. DeathB 




| Deaths 

Cases. Deaths. 


Samara (town). 

i b 


2 3 

i i 


2 — 




1 — 

383 204 

„ (government) . 



34 | 20 



38 27 





759 381 

Astrakhan (town) . 



2 | — 


— — 





1683 873 

Arkhierei and Ataman. 



1 — 

1 - 


— — 


' — 



461 290 

Astrakhan (government) ... 



il - 


— — 





796 376 

Saratof (town). 



—- j — 



— — 





210 62 

Tsaritsyn (town) . 



2 3 


— — 




586 I 291 

Saratof (government). 



S 3 



4 — 




I 413 197 

Kazan (town) . 



1 32 11 



1 13 9 





203 113 


,, (government). 



1 1 



2 1 





- - 

Nljni-Novgorod (town). 



9 | 2 



2 1 





1 245 97 

„ „ (government! 



14 9 



8 4 





497 242 


Simbirsk (town) . 



_ _ 


| — 

— — 




5 ! 4 


m (government). 



3 1 



— — 





353 1 170 


Yaroslavl (town) . 



— — 



3 2 





60 30 


•f (government. 



6 , 1 



— 1 





52 I 22 


Penza ,, . 



- - 



7 2 





160 78 

tt (town) . 


_ — 







9 2 


Vladimir (government) 



— — 




6 2 


Moscow (town). 

— 1 


— — 



— | — 





2 1 

•« (government). 

— 1 


_ — 



— — 




15 8 


Kostroma (town) . 



_ — 



— 1 





53 22 

•• (government) ... 



6 , 1 



— 2 



205 100 


Ufa (government). 



2 1 2 



— : — 



11 10 

Viatka (town). 



— I — 


— ; — 



9 1 

i« (government) . 



— — 



— j — 



15 6 

Perm (town) . 

— | 

— — 



— — 





15 10 


tt (government) . 




— — 







6 5 


Ekaterinoslav (town) . 



29 13 



15 10 





146 76 


„ (government) 

i j 


8 1 







37 11 

Don Territory. 



63 21 



14 16 





201 1 102 

Bostof on Don. 



28 16 



11 j 8 





204 1 106 

Kishlncf (town) . 










1 - 


Kief (town) . 



543 126 



147 57 





1237 305 


„ (government). 



26 21 



49 j 15 





186 75 


Volhynia (government) 



— — 



— — 





14 9 

Tchernigof „ 



25 11 



13 13 





98 63 




— — 



5 — 





11 4 





11 3 



5 2 





35 16 


Kharkof (town) . 




5 1 



— — 




5 1 


„ (government). 



— - 



4 3 





16 12 


Kiazan (town) . 


— — 






3 “ 

t* (government). 



— — 



— — 





7 5 


Kursk ,« . 



7 2 








95 49 

Minsk .. . 




_ — 








5 2 


Mogilef .t . 



- - 





1 | 

39 13 

Tambof tt . 



— — 






— i 

1 — 

oronezh „ 



— — 



— — 





4 1 


Theliabinsk (town) . 



7 3 



— — 





23 11 

Orenburg (government) ... 



— — 

— 1 


5 4 




52 36 

Asiatic Russia. 

Tiflis (town) . 



— — | 







1 1 

Baku (town) . 



24 16 



23 8 





147 77 


tt (government) . 



— — 



— — 





1 1 


Black Sea Government 



— — 



— — 





1. 1 


Krasnovodsk (town) . 



— — 



— — 





1 1 


Krasnoyarsk „ . 



— — 



— I — I 




13 7 


Tashkent „ . 





— 1 — 1 




7 1 


Syr Daria Territory . 





— 1 — 




~ i 

2 2 

Turgai Territory . 






— — 





12 10 

Semipalatinsk (town) . 



8 8 



— — | 



22 16 

„ (territory) ... 



18 5 ; 



— — 




35 15 

Akmolinsk ' ,« 



28 16 



18 9 





548 239 

Tobolsk (government). 



34 14 



— — 




— 1 

154 73 

Tomsk (town) . 



n l 



3 2 




- ! 

42 13 

„ (government) . 




101 60 



42 18 





822 470 

Yeniseisk (government) 



— — 



— — 





15 12 

Irkutsk (town). 



3 — 



— — 





29 13 

Transbaikal (territory). 



— | — 1 



— — 




— 1 

2 1 




1702 | — | 



— — 





11,472 5493 


[JAN. 4, 1908. 

bacteriologically it appears not to have been one of cholera. 
No other cases occurred in Stamboul. 

A far more serions outbreak of the disease is now running 
its course at the lazaret of Sinope, on the southern shores of 
the Black Sea. The pilgrim steamer, Gregory Merck, which 
had left Odessa on Nov. 22nd (New Style), arrived at Sinope 
on the 24th with 2100 Moslem pilgrims on board. They were 
subjected to the five days’ quarantine now in force for such 
ships. Some suspicious deaths seem to have occurred among 
them at or before their arrival there. On the 28th it was 
reported that a severe outbreak of cholera existed among the 
pilgrims from this ship and the daily telegrams received 
since have confirmed both the intensity of the outbreak and 
the difficulty in bringing it to an end. Between Nov. 27th 
and Dec. 1st 54 cases with 36 deaths were reported ; on the 
2nd there were 2 new cases and 1 death, on the 3rd 5 cases 
and 6 deaths, on the 4th 4 cases and 5 deaths, and on the 
5th 3 cases with 3 deaths. The totals on the 5th had reached 
the high figures of 68 for the cases and 51 for the deaths. 
This outbreak proves once more, if proof were needed, the 
exceptional danger that masses of Moslem pilgrims present 
for the spread of cholera. It is noteworthy that Odessa, the 
port they had sailed from, is, so far as is known, a ’‘clean ” 
port—that is to say, no case of cholera is known to have 
occurred there. The pilgrims in question had, however, evi¬ 
dently come from, or traversed, some of the infected regions 
enumerated in the accompanying table, and the infecting 
material there acquired must have remained dormant, either 
in their persons or in their clothes or effects, until about the 
time of their arrival at Sinope. 

In consequence of this outbreak it has been decided 
that all ships from Russian ports of the Black Sea will 
undergo a thorough inspection on arriving at Kavak at the 
entrance of the Bosphorus ; if a case of cholera is found on 
board the ship will be sent to the Sinope lazaret (if it is in a 
condition to receive any more ships) or to the Russian 
lazaret of Theodosia, where the Russian Government has 
consented to receive them. If no case is found at the inspec¬ 
tion the ship, if there are no pilgrims on board, will be 
quarantined at the Kavak lazaret; but if there are pilgrims 
on board she will be sent to the Clazomene lazaret, near 
Smyrna. A number of other measures, which it would take 
too much space to mention in detail, have also been put in 
force to diminish the risk of further spread of cholera by 
pilgrims travelling from Russia by sea or land. The 
measures on land have been shown to be necessary by the 
discovery that a number of pilgrims were leaving Russian 
territory by way of Roumania or Hungary and, striking the 
main Oriental railway at some point, were arriving in 
Constantinople by train. In addition to the above measures 
the Board of Health has formulated a “j;«•«," desiring the 
Russian Government to do all in its power to prevent the spread 
of the disease by its pilgrims and adding that the end could 
best be attained by subjecting those pilgrims to disinfection 
and isolation for a fixed period before their departure from 
Russian territory. Under Article 87 of the Paris Sanitary 
Convention of 1903 this measure is compulsory, if local 
circumstances permit, if the port where the pilgrims embark 
is infected. It is not, perhaps, clear whether this article is 
of general application, or applicable, like Article 86, only to 
ports of the Indian Ocean and Oceania. It is in any case 
desirable that the preliminary observation befoie departure, 
which has proved to be of such value in India in preventing 
the spread of plague and cholera from that country, should 
also be applied to pilgrims leaving Russian Black Sea ports. 
The outbreak at Sinope has shown what a real danger those 
pilgrims can be ; indeed, owing to the proximity of the ports 
in question, such pilgrims offer a greater danger for the rest 
of Europe than those embarking in ports of the Indian 
Ocean or Oceania. 

Some cases of cholera recently occurred in the lazaret of 
Camaran, in the Kid Sea, among pilgrims from two British 
ships. There were three cases from the first ship and three 
from the second. In reviewing the records of this great 
lazaret it is a striking fact that between 1890 (when complete 
records begin) and 1895 inclusive cholera was imported there 
on 11 occasions ; between 1896 and 1906 inclusive it was not 
imported on a single occasion : now, in the first two months 
of the 1907 pilgrim season, it has been twice imported. In 
1896, it will be recalled, plague first appeared in Bombay ; 
in 1897 the pilgrimage from India was prohibited ; since that 
date it has been permitted, but under certain precau¬ 
tions, the most important of which have been the indi¬ 
vidual inspection of the pilgrims before embarking, the 

disinfection of their clothes and effeots, and the isolation of 
the pilgrims in an observation camp for a fixed period before 
their departure. Some or all of these measures remained in 
force until the autumn of 1906, when the isolation before 
departure was abandoned owing to the fact that the pilgrim 
season, now and for Borne years to come, tends to fall more 
and more in the rainy season when such camps become 
almost uninhabitable. The fact that the Camaran lazaret 
(to which all Indian pilgrims are sent before admission to 
the Hedjaz) remained free from cholera from 1896 to 1906— 
that is to say, for just that period during which the 
departure of pilgrims from India was prohibited or only 
permitted under strict precautions—whereas in the six pre¬ 
ceding years importations of cholera there were frequent, 
and in the early months of the subsequent season two such 
importations have occurred, shows in a very striking manner 
the great value of the precautions in question, and justifies 
the conclusion that among those precautions the isolation 
of the pilgrims before departure must be regarded as one of 
the most efficacious. The measures in question, it should be 
added, were imposed with a view to prevent the spread of 
plague from India, but they have been equally effective in 
controlling at the same time the diffusion of cholera. 

The reports received here of the behaviour of cholera in 
Persia are very incomplete and conflicting. Some cases 
appear to have occurred in the fisheries on the southern 
shores of the Caspian ; on one or more ships plying between 
Astrakhan and Persian ports ; and at Astara, close to the 
Caucaso-Persian frontier. A deadly epidemic is stated to be 
decimating the garrison and population of Kuh-Malik-i Siah, 
on the frontiers of Persia and Beluchistan, but the nature of 
the disease is not known. Persia is reported to have closed 
her Russian land frontiers, except at the four points of 
Djulfa, Khoudaferin, Astara, and Bhahtadfi, where passengers 
are submitted to a medical inspection and other measures. 

Constantinople, Dec. 9th, 1907. 


A Vast Experiment in Ventilation.—An Example 

(From our Special Sanitary Commissioner.) 

The Luritania and the Mauretania are two floating 
towns. Big liners have often been compared to floating 
hotels ; but in any case, for these, the two largest ships in the 
world, the word “ town ” is more appropriate. Besides, the 
word “ hotel ” does not cover all the intricacies of the problems 
that have to be solved and the difficulties that must be over¬ 
come. A hotel may be a first-class or a second-class hotel; 
there are not different classes of hotels under one and the 
same roof and management. These big ships, on the contrary, 
are not only first-class hotels but they aie also second-class 
and third-class hotels and hold besides quite a large pro¬ 
fessional, artisan, working-class, and labouring population. 
In a word, all the gradations of people and occupations which 
constitute the population of a town are to be found on 
board. There is the fashionable promenade deck, where of 
late, on the Booth Line as well as on the Cunarders, has been 
introduced the French caf6, with its terrace, round tables, 
and light refreshments served in the open air. Adjoining 
there are not the small cabins where two or four pas¬ 
sengers sleep in such restricted space that only one of 
them can dress at a time but regal suites of rooms, 
drawing-room, dining-room, bedrooms, with real beds 
instead of bunks, and a private bathroom. Yet, while 
there are public and private saloons and other apart¬ 
ments that equal in luxury and art decorations the most 
beautiful palatial residences, these floating towns have also 
their poor industrial districts and even what might almost 
approximate to their slums. It is the firemen’s quarters that 
generally constitute the slum of a ship. On shore there are 
two main causes that bring about the existence of slums. 
There are, on the one hand, the defective construction of the 
dwellings and the unscrupulousness of the speculators in slum 
property ; and, on the other hand, the disorderly, thriftless, 
and dirty habits of the dwellers in the seslums. Legislation, 
at sea as on shore, has stepped in to mitigate these evils. 
At sea the law U6ed to stipulate for 72 cubic feet 
of space and this has now been increased to 120 cubic feet. 
The law not only attempts by such enactments to prevent 
o vercrowding in the quarters occupied by a ship's crew but 

Thk Lancbt,] 


[Jan\ 4, 1908. 55 

it also insists on some sort of ventilation. How such ventila¬ 
tion is to be given in a thoroughly efficient manner is a 
problem that neither the law nor any other authority has 
satisfactorily solved. Fortunately there is now before us 
in these two big ships an earnest attempt made to 
deal practically with the whole question. This endeavour 
commends itself all the more to public notice inasmuch as 
whatever is being done is not done merely for the saloon 
passengers but more especially for the crew and the third- 
class passengers. 

As with some of the dwellers in the slums of our great 
cities, so with the firemen on board, legislation can hardly 
force them to be clean ; but by insisting on 120 cubic feet 
per man this means that there shall be room for lavatories 
and space to wash. The English firemen, and especially 
those recruited at Liverpool, have the reputation of being the 
dirtiest men afloat and they are also the hardest drinkers. 
So we have here the required characteristics for the creation 
of a slum. On the other hand, this dirty and intemperate 
rough is just about the hardiest, the most plucky, and the 
most persistent worker that can be found in any part of the. 
world. It is only with such men in the stokehole that the 
blue riband of the Atlantic can be won. But from the sanitary 
point of view they constitute perhaps the most difficult 
problem that has to be solved. Fortunately, the firemen’s 
dirt is more offensive in appearance than in reality. His dirt 
mainly consists of coal dust and this has a purifying rather 
than a corrupting action. Another great difficulty is that 
after exposure to the scorching furnaces and the heat of the 
stokehole, the firemen, when lying down to rest in their 
bunks, are especially sensitive to draughts. Any ventilator 
admitting cold air at too great a velocity will very promptly 
be closed. In the firemen’s quarters more than in any other 
part of the ship is it necessary to divise means for intro¬ 
ducing a plentiful supply of fresh air without creating a 
draught. Thus it will be seen that on a great ship as in a 
town it is with the poor, the careless, and the dirtier sections 
of the community that the most puzzling administrative diffi¬ 
culties arise. 

Certainly magnificent ships like the Lusitania and 
Mauretania represent exceptionally prosperous towns, such 
as fashionable watering-places frequented by very wealthy 
people and where real poverty and squalor are almost un¬ 
known. Thus out of a total possible population of 3250, 
which both ships can carry, 550 would be first-class and 500 
second-class passengers, and they may be taken as repre¬ 
senting the upper and middle classes. Then there is room 
for 1300 third-class passengers and the crew is set down at 
800 to 900. How navigation has changed of late years is 
Bhown by the fact that while the engineering depart- 
ment employs no less than 390 persons the sailing 
department only employs 70 officers and seamen. Then 
there are 350 stewards, a number of stewardesses, 50 cooks, 
a band, telegraph and telephone and lift attendants, printers, 
and others, making up a total crew numbering from 800 to 
900 persons. The crew represents a population of workers 
of all ranks from the captain, the surgeon, and the superior 
officers who belong to the liberal professions down to the 
coal trimmer or the washers in the scullery who may be 
taken as 1 elonging to the unskilled labouring class. To 
house, to feed, and to keep in health such a mixed population, 
Buch a variety of classes, to say nothing of the variety of 
nationalities, constitutes a series of problems which resemble 
the difficulties that beset the administration of a town 
rather than the management of a hotel. All these people, 
differing so greatly one from the other, have all equal need 
of lodging, food, and cleanliness of person, clothes, and 

In regard to the food supply, the population of these 
large ships are better oil on board than onshore. Cooking 
done on a large scale is likely to be more clean and much 
cheaper than done in detail. Also the food is more strictly 
examined, not merely according to the usual methods, 
but also by the special Board of Trade inspectors. 
Therefore it is prooable that more unwholesome food 
would be found in the retail shops of a town than on 
board ships leaving an English port. In thus comparing 
these very large ships to a small town the fact 
will become evident that we have here an attempt at 
collective administration for an entire community that 
may set an example capable, at least in some phases, of 
application to towns that do not float across the Atlantic but 
are content with remaining affixed to terra firma. Speaking 
now exclusively of the Lusitania and the Mauretania , two 

small floating towns with populations comprising all classes 
and varying from, say, 2300 to 3250, we have provided for all 
these people one and the same system of ventilation and 
likewise the same unique system of cleanliness and washing. 
It is just conceivable that we may find in this a working 
example of what might be done, if not for an entire town at 
least for a district, a cluster of dwellings, especially large 
tenements and blocks, and more particularly for clusters of 
small workshops where industrial dust and inefficient 
ventilation play havoc with the working population. 

Over and over again when dealing with ventilation, 
whether of a great building, a theatre, or, for instance, 
the Paris Sorbonne, or only Dr. T. Glover Lyon’s modest 
and private dining-rcom where not more than 14 persons 
can sit at table, the same inevitable conclusion forces 
itself forward. Obviously no method of ventilation can 
be satisfactory unless mechanical force is employed, and 
intelligently employed—that is to say, modified from 
time to time as the conditions dealt with themselves 
alter. It is alto obvious—and this is admirably demon¬ 
strated by Dr. Glover Lyon's experiment 1 —that mechanical 
force and scientific ventilation could only be obtained 
by very wealthy persons if provided especially and solely 
for one individual. In the case in question the installa¬ 
tion for ventilating one single small room would cost at 
least £150. On board the big ships in question, however, 
ample mechanical ventilation is supplied not merely to the 
wealthy saloon passengers but also to the steerage or third- 
class emigrants and to the poorest among the unskilled 
workers forming part of the crew. All, rich and poor alike, 
workers and idlers, passengers and crew, have fresh air 
pumped down to them all day and all night by mechanical 
power. Doing this on a wholesale scale certainly does not 
cost anything like £150 per room capable of sealing 20 to- 
dinner. It would be of considerable practical use to know 
what is the cost per head of the mechanical ventilation 
applied to these ships. 

The system as installed on the Mauretania has already 
been described.’ This was, however, a theoretical descrip¬ 
tion, and since then I have had a brief opportunity of seeing 
the same system in actual work on board the Lusitania. 
With the courteous permission of the Cunard Company, and 
accompanied by the ship’s surgeon and also by members of 
the staff of engineers, I visited all parts of the ship while 
she was on her way from Liverpool to Queenstown. The 
weather, however, was not propitious. Everything went 
wrong and the only consolation is that there is no 
reason why the experiment should not be repeated 
in more favourable circumstances. At 7.30 p.m. on 
Saturday, Nov. 30th, the Lusitania was to start from the 
Liverpool landing stage for Queenstown and New York. At 
midday I was to take the large tender, the Skirmisher, meet 
the chief engineer, Mr. Leonard Peskett, and spend the 
afternoon with him examining the whole system of venti¬ 
lation before the ship came alongside the pier to embark the 
first- and second class passengers. Mr. Peskett managed to 
get on a small tender with some workmen. After crawling 
through the fog for an hour they came upon the Lusitania 
and it was only after bumping up against her Bides that they 
discovered it was the ship for which they were looking. The 
other tender which I was awaiting was lashed alongside the 
Lusitania and did not venture to leave the ship till some 12 
hours later, at about 1 o’clock in the morning when the fog 
lifted. In vain I waited on the landing stage in the thick of 
the fog from noon till nearly 4 o’clock in the afternoon. Some 
800 emigrants were there also, as they should have gone on 
board in the morning by tenders. They suffered from cold and 
damp, then later from hunger. The little buffet on the land¬ 
ing stage was soon stripped of all its provisions. There were 
other ships, a Booth line steamer for Portugal and the 
Brazils and an Elder Dempster line steamer, to say nothing 
of the cross Channel services to Ireland and the Lie of Man 
with their quota of passengers, all on the look-out 
for tenders or ships that could not find their way 
through the fog, and as these people, numbering more 
than a thousand passengers, waited and waited for 
hours they got more cold, more damp, and more hungry. 
The smaller steamers were at anchor near the landing stage 
and tenders managed to get off to them later in thealternoon. 
Bat the huge Lusitania was anchored far away near Hock 
Ferry and in so thick a fog could not be reached by the 
tenders. Food in carts and great caldrons of hot tea and 

1 See The Lamckt, March lot, 1902, p. 620. 

* See The Laxcet, Nov. 23rd, 1907, p. 1182.) 

56 The Lancet,] 


[Jan. 4,1908. 

coSee had to be brought down to the landing Btage bo that 
the emigrants might be fed and kept warm. Finally the 
hope of Btarting that day was abandoned and all the 
emigrants marched back to their lodgiDgs, and rooms were 
secured in the hotels for the first- and second-class passengers. 
By this time I had learnt something as to the difficulties 
of navigation in such a climate as onrs but was not any 
further enlightened in regard to the problem of ventilation. 
Fogs of such density as completely to paralyse all traffic 
on the Mersey do not often occur but they are to be expected 
occasionally. As, however, they may at any moment and 
quite suddenly disappear the passengers dare not leave 
the pier. In such circumstances it seems to me that 
better shelter and better and more numerous fires might be 
provided in better furnished and more comfortable wait¬ 
ing rooms. The Prince's landing-stage at Liverpool is a 
very pleasant and interesting place on a fine summer's day 
but it is just the reverse during rigorous winter weather. 

On the next morning a little after 6 o’clock telephone 
messages were ringing up the passengers at all the hotels and 
by 8 o’clock a large crowd had already gathered on the 
pier. Soon the great ship loomed through the morning haze 
and was lashed alongside ; then with incredible speed all 
the passengers and all their luggage were taken on board. 
This haste, however, was of no service ; the big ship moved 
away from the landing stage but could only descend the 
river a mile or two and then the fog once more thickened 
and it was necessary to cast anchor. But, in any case, I 
was at last on board the ship and profited by this delay to 
have a thorough look round. It was, however, soon obvious 
that the ventilating system was not yet in working order. 
The experience acquired on this occasion was very valuable. 
It conclusively demonstrated that it does not suffice to have 
a Bystem of ventilation installed, however perfect it may be. 
Indeed, it seems only natural to conclude that the better the 
system the greater will be the intelligence required in its 
handling. It is only technicians who should be intrusted 
with instruments of precision. It would not be wise to hand 
over expensive chemical scales to the tender mercies of a 
greengrocer. Obviously the study of navigation does not 
include the management of ventilating fans and steam coils 
used for warming purposes. On the Luritania the officers’ 
quarters really consist of a small separate house built on the 
upper—that is, the navigation—deck, with its own special 
thermo-tank on its roof or deck. These thermo-tanks, the 
manufacturers state, ‘ ‘ are capable of changing the air either 
by exhaust or supply in the various compartments to which 
they are connected at least ten times per hour and they are 
also capable of maintaining a temperature of at least 65° F. 
in the coldest weather.” Doubtless this is so when 
they are properly managed. Fig. 1 is the reproduc¬ 
tion of a photograph which I took of the thermo-tank 

Fia. 1. 

The thermo-tank ventilating and warming apparatus for the 
officers’ quarters. 

above the officers’ quarters. There is, it will be seen, no 
lack of means to regulate the supply of air and heat. 
Nearest to the part containing the rotary fan to the left is a 
valve for regulating this fan when used for exhausting pur¬ 
poses. In that case the mushroom covering of the cylindrical 
part which contains the steam coils is raised to enable the air 

drawn from below to escape. If the fan is made to revolve in 
the contrary direction then it pumps air down after passing it 
over the steam coils when it is desirable that it should be 
warmed. The second valve regulates the supply of air ; the 
third regulates the supply of steam to the heating coil; and 
the fourth regulates the flow of steam from the heating coil 
back to the condenser. But that is only a part of the 
mechanism. There are means of regulating the velocity at 
which the fan revolves when it pumps the air into the 
ship and so directing the fresh air that only a portion of it 
goes over the heating coils and the rest descends fresh into the 
cabins. There is also means of discharging a small atomised 
steam-jet into the air so as to add moisture in excessively dry 
weather. With all this at their disposal I had hoped to find 
the officers living in an ideal atmosphere and temperature. 
As a matter of fact, the apparatus had been so worked 
that after suffering from such excessive heat that 
the woodwork in the cabins showed signs of warping 
the officers were glad to cut off all connexion with their 
thermo-tank. Consequently, as there were no other means 
of warming, the cabins were very cold, and as for 
ventilation that depended on the accident of open doors or 
portholes. Of course, this state of affairs will not last. 
The thermo-tank will have been set to work again and this 
time it is to be hoped properly regulated. But the incident 
is instructive, because it shows that even with the best 
machinery ventilation cannot work automatically : it must 
be watched and controlled carefully and by a technician. 

In the firemen’s quarters the experience was just the 
reverse ; their thermo-tank was working vigorously, in fact 

Fig. 2. 

A therrao-tank for the second-class cabins, showing the " starting 

too vigorously, and the air which it sent down was too cold. 
Consequently most of the air inlets were closed. A fireman 
was attempting to sleep in an upper bunk within three or 
four feet of the trunk shaft in which the air descends and 
which is affixed to the roof of the cabin. There was a 
valve just facing this fireman and I opened it. Obviously 
had 1 not closed it again the man could not have 
remained in his bunk. The cold air rushed in with great 
force creating a dangerous draught. Evidently the thermo¬ 
tank supplying this compartment was working too fast and 
had not warmed the air sufficiently, if at all. Then there 
was no sort of bailie, nothing to break up and to disperse the 
current of air as it rushed through the valve aperture. But 
it is not necessary to pump the air down at such a rate that 
it creates a nuisance. Fig. 2 shows a thermo-tank placed 
outside a structure which • serves as a light and air trunk to 
the condenser room and stands on one of the decks reserved 
for the second-class passengers. Above and to the left a 
small box-like arrangement with two pipes coming out 
underneath is called the “ starting rheostat.” This is used 
for starting and regulating the speed of the fans. Therefore 
the velocity at winch the air travels can be controlled ; only 
someone must watch in order to see what is needed and to 
act accordingly. Then I photographed a row of thermo-tanks 
near the great funnels which supply the first-class state¬ 
rooms. (See Fig. 3.) Just as the air leaves the thermo¬ 
tank and commences its journey to the cabins below a small 
hole has been out in the trunk air shaft and a thermometer 

Tas Lancet,] 


introduced. There is a thermometer thus attached to ever} 
thermo-tank and it is therefore easy to ascertain promptly 
what is the heat of the air pumped down into the ship. But 
again someone must see to this and find out what the heat 
ought to be according to the distance to which the air has 
to travel, the needs of the part of the ship which it has to 
supply, and the general condition of the weather at the time 
in question. 

To meet these ever-varying conditions numerous and very 
careful experiments will have to be made. Every thermo- 
tank bears an inscription stating what part of the ship 
it supplies, and considering the variety of the distance and 
the disposition of the different compartments no one rule 
would apply. On the Mauretania there are 65 thermo-tanks 
and they pump air through 17,000 feet of trunking. Thus 
there are in all three and a quarter miles of air channels, made 
for the most part of galvanised sheet iron and including 
some 5000 bends, T-pieces, &c. Is it conceivable that air 
can be automatically propelled along this enormous distance 
at exactly the rate and temperature desired ? All honour to 
the constructors of these splendid ships for having introduced 

Fl3. 3. 

A row of thermo-tanks supplying air to the (irit-elass state-rooms. 

such a vast and comprehensive system of warming and venti¬ 
lating. But it would be a fatal illusion to imagine that ail 
this will work when once wound up like an eight-day clock 
and that it need not be touched again till the end of the week. 

The Lusitania has not quite as many thermo-tanks as the 
Mauretania but there is no practical difference between the 
two ships. When I looked at the thermometers attached to 
the thermo-tanks I found that their temperature varied from 
55° to 120° F. ; this showed that some of these apparatus 
had not yet been regulated. Doubtless all this was rectified 
when the ship got further under way. Bat the fact that this 
was not done at starting shows how difficult is the problem 
and how much still remains to be achieved before experienoe 
has taught the lessons that have yet to be learnt. It will be 
necessary to secure the services of a few thoroughly com¬ 
petent engineers to regulate these apparatus, to visit 
and to watch over all parts of the ship, and to be constantly 
verifying whether the system is working properly. It will 
also be necessary in many instances to make considerable 
alterations in the valves, notably in the firemen’s quarters, 
where the air is admitted, so that it may be split up, diffused, 
and not create an injurious draught. But it will at onoe be 
seen that these finishing touches to the system represent a 
mere trifling outlay when compared with the vast sums that 
must have been spent over the thermo-tanks, the 2000 h.p. of 
electricity used, among other purposes, for settiDg the 
fans in motion, the three and a quarter miles of air trunks, 
the condenser and steam-heatiDg coils, Ac. We have now 
reached the stage when it is only necessary to apply the 
old saying, namely, “Not to spoil the ship for the sake of 
a pennyworth of tar.” There can be little doubt that 
in the course of a few months when the necessary experience 
is acquired the great problem of warmiDg and ventilation 
will practically be solved in regard to these great ships. 
Indeed, I have just been informed that the patentee of the 
ventilation apparatus and the draughtsman who had charge 
of this particular section of the work sailed in the Mauretania 

[Jan. 4, 1908. 57 

on her last voyage to regulate the valves and to see to all the 
details. As a result no complaints have been made. On 
Saturday, Dec. 28th, the manager of the ventilating system 
and the draughtsman sailed with the Lusitania and it is 
anticipated that they will be equally successful in putting 
everything in order. The whole system has been carefully 
gone over and there is no reason why the defects should not 
oe remedied now that efficient technicians are on board. If 
so we shall have here a most valuable object-lesson. 
Throughout I have compared the ships to towns, and I 
believe that much of what is done on board could with equal 
economy and benefit be applied on shore. Why not consider 
a thoroughfare of large houses, such as Victoria-street, to 
represent on one side the Mauretania and on the other side 
the Lusi'ania, and proceed to warm and to ventilate all the 
rooms in a similar manner? The experience now in the 
conrse of acquisition on board these great liners may be of 
use on shore as well as at sea. The entire nation has 
manifested enthusiastic pride in these magnificent record- 
breaking ships. For my part I see their utility not merely 
in regard to quick and lnxnrions travelling but as a vast field 
of experimentation where some of the most difficnlt problems 
affecting the sanitation of dwellings and of workshops may 
find an effective and economic solntion. 


(From our own Correspondent.) 

luberculous Milk. 

The medical officer of health, Dr. J. Robertson, reports that 
after prolonged investigation it is found that 14 per cent of 
the milk sent into Birmingham contains living tubercle 
germs. The health committee, having considered the 
report, has decided to recommend that, in the event of the 
Government not taking the matter up and as the existing 
legal powers are not sufficient to enable effective steps to be 
taken to deal with this “ grave danger to the public health,” 
additional local powers shall be sought. The position of the 
health committee would be strengthened if it could give 
some definite idea of the effect produced by the contaminated 
milk in any particular cases. 

The\Medical Students’ Dinner. 

The annual dinner of the Birmingham University Medical 
School was a more than usually successful event. There was 
a good attendance to meet Dr. W. Hale White and Dr. 
William Wright, the latter of whom was a great favourite 
with the Btudents when he held the post of senior demon¬ 
strator in the anatomy department at Birmingham. The 
speeches were good but rather long, and the humorous vein 
was a little lacking except in Mr. H. G. Barling's reply for 
the medical school. One opinion that Mr. Barling expressed 
when he passed into a serious phase is well worthy the 
attention of the public and of the authorities of schools who 
are constantly struggling to increase the number of their 
students. He stated that he would prefer 100 well-educated 
medical men to 200 who were imperfectly educated, and he 
expressed the belief that the public would be better served 
by the former than by the latter. 

Distribution of Prizes at the Dental Hospital. 

Considering the great demand there is in the Midland 
district for dentists, it is somewhat surprising to learn from 
the statements of the speakers at the annual distribution of 
prizes at the Dental Hospital and at the annual dinner of 
the Dental Students’ Society that the number of the students 
at the Dental Hospital does not exceed 30. The only reason 
that can be assigned is that in years gone by the Dental 
Hospital did not offer all the facilities which could be desired. 
Such, however, is not the case to-day; the hospital is now 
ODe of the most efficiently equipped in the country and the 
staff are energetic and determined. It may be hoped, there¬ 
fore, that the number of the students will rapidly increase 
and that the wants of the district will be properly supplied. 
Mr. W. F. Haslam. who spoke after the distribution of the 
prizes, drew special attention to the necessity of students 
avoiding desultory reading, and his remarks are particularly 
important to Birmingham students who have a tendency to 
distribute their energies over too many objects at one time. 

Hospital Sunday Collections. 

At last the full accounts of the Hospital Sunday collec¬ 
tions in Birmingham for 1907 are to hand and they show 

58 The Lancet,] 


[Jan. 4, 1908 

an ' improvement of about £300 on the collections of 
the previous year. So far as it goes this is satisfactory, 
but it is not what was hoped for, and it appears from 
the statement of the Lord Mayor, who presided at the 
recent meeting of the friends and supporters of the Hospital 
Sunday Fund, that the active sympathy and help of all 
religious denominations which it was hoped would be 
secured on behalf of the collections were not obtained. 
This is greatly to be regretted, for the one virtue which 
should be common to all religions is that of charity. 
Whilst it mnst be admitted that the Hospital Sunday 
collections in Birmingham were not what was desired, 
the case in Dudley is still worse. In the area from which 
the Guest Hospital, the Dudley Dispensary, and the Dudley 
Eye Infirmary receive patients are 146 churches and chapels 
and the average amount which they collect for hospital 
purposes is £67 per annum. This is scarcely surprising when 
it is found that at a meeting called to discuss the question, to 
which the heads of all the religious bodies had been invited, 
only three ministers and three laymen attended. Clearly 
there is something wrong in the Dudley religious organisa¬ 
tions, and unless some adequate explanation can be put 
forward the surrounding districts will be inclined to point to 
Dudley as an example of considerable laxity so far as the 
Hospital Sunday Fund is concerned. 

The Health of Brass Casters. 

An inquiry has recently been held in Birmingham at which 
evidence was produced by the employers who object to some 
of the draft regulations which the Home Department has 
proposed with the object of regulating the arrangements 
in brass-casting works in order that the standard of health of 
the workers may be improved. So far as the Birmingham 
trade is concerned it is obvious that in fairness to the workers 
something must be done, and judging from the statements 
made by some of the witnesses useful and efficient 
means of diminishing the dangers of the work by removal 
or dispersion of the dangerous fumes can be adopted 
without the incurring of any prohibitive cost and without 
impairment of the efficiency of the work. Apparently, how¬ 
ever, the brass casting in other places is not the same aB in 
Birmingham and an application was made to the Home 
Office Commissioner that further evidence should be taken in 
Glasgow, Newcastle, and London before final regulations 
were decided npon, and to this obviously reasonable proposi¬ 
tion the Commissioner agreed. There can be little doubt 
that a fair solution of the difficulty of dealing with what is 
an acknowledged evil will eventually be arrived at and that 
the workers at the trade of brass casting will materially 

Dec. 31st, 1907. _ 


(From our own Correspondent.) 

Christmas in Manchester. 

From Christmas Day, and even from a few days earlier, to 
the close of the old and the advent of the New Year Man¬ 
chester is much given up to holiday, and the same is true of 
Lancashire as a whole, ft is sometimes said that this festival 
season is more generally, or at all events more heartily, kept 
than in the south ; bat however that may be, Manchester can 
claim that " Dr.” Byrom. the author of the best and widest- 
known of all Christmas hymns, “Christians, awake," was one 
of her townsmen, and that Wainwright, the composer of the 
tune almost universally sung to it, was from Stockport. 
Byrom studied medicine at Montpellier and waB termed 
“ Dr.” by his friends, but he never took his degree. He 
was an adherent of, or at least favourable to, the cause of 
the Stuarts, as is pretty evident from the toast to the King 
which he is said to have proposed. The version known to 
the writer, for there are said to be some slightly varying, is 
as follows:— 

God bless the King, God bless the Faith's Defender, 

G< d bleBa—no harm in blessing—the Pretender; 

But which Pretenner is, and which is King, 

God blesB us all, is quite another thing. 

The season is marked at the various hospitals by entertain¬ 
ments to please both young and old, and the inmates of the 
workhouses are'not forgotten. Perhaps the Christmas 
festivity at the Children’s Hospital at Pendlebnry may 
be taken as an illustration of what is done to brighten, 

for the time at least, the pain and weariness from 
which the patients too often suffer. There are about 
160 children there and on Christmas morning each one 
finds at the comer of the bed a stocking full of odds 
and ends. Then large Christmas trees are brought into 
the wards and round them the nurses are very busy. In 
due time the trees burst out in a display of coloured 
lights, while more or less bulky parcels are seen hanging 
from the branches, each one having the name of one 
of the little patients, all of whom are keenly interested in 
the proceedings. The routine of the hospital cannot be 
suspended too long, but for two hours the children were 
allowed not only to enjoy their new toys but to be made 
much of by the visitors whose sympathy and kind words 
must often cheer the sufferers. The patients are all under 
14 years of age and receive presents suitable to their years, 
some of the older girls, for instance, having work-boxes. 
Carols were also Bung by the members of the choir of 
Holyrood Church, Swinton, who walked in procession through 
the wards and corridors. There are, of course, differences 
in the procedures at the various hospitals, but the main object 
is to add to the enjoyment or to lessen the sufferings of the 

A Large Family. 

A female claimant at the St. Helens county court 
surprised the judge one day lately by saying that she had 
plenty to do with the money, as she bad 21 children. This is 
unusual enough, but even this family was smaller than that 
of a late rector of Eccleston, near Chester, who was some¬ 
times said to have had 21 children twice over, the fact being 
that after the death of the twenty-first child another was 
born, so that his wife was the mother of 22 children. 

Death of Mr. E. M. Wilkins , M.B. Viet., M.R.C.8. Eng. 

Dr. Eric Maurice Wilkins, son of the late Professor Wilkins 
of the Victoria University, was found dead yesterday at his 
house in Victoria Park. No details are as yet known. He 
was 27 years of age and was a remarkably skilful athlete. 

Coroner's Busy Day. 

The festive season is too often shadowed by tragedy. 
Nearly 20 sudden deaths were reported the other day and 
inquests were held in 12 cases and the jury were occupied in 
viewing bodies (that old custom against which so much can 
be said and something also in its favour) for almost three 
hours. Four children sleeping with their parents were found 
dead in bed. The coroner took a very charitable view of the 
matter, attributing it in part, at all events, to the very cold 
weather. In all likelihood the children habitually slept 
with the parents without fatal accident, but if the in¬ 
dulgence of a little extra drink at Christmas time had 
been yielded to the probability of overlying would be 
enormously increased. It is, however, the idea among 
parents that there is no danger in the practice if we may 
judge by the answers to the questions put by the coroner. 
Two women, one aged 50 and the other 58 years, were killed 
by falling down cellar steps on Christmas Day. 

Crowded Asylums. 

The overcrowding of the County Asylum is becoming more 
acutely felt. The Lancashire Asylums Board has intimated 
to various boards of guardians that it wishes them, if 
possible, to accommodate some of the harmless chronic 
patients. The Prestwich guardians have just discussed the 
subject. It was suggested that when the new union 
infirmary was opened in the year on which we are just 
entering some room would be available at Crumpsall. The 
house committee is to consider the question. It seems 
as if all estimates tend to grow so vigorous as to be irre¬ 
pressible. Then, too, the problem of the unemployed, some 
of whom [if they seek for employment do not want work, and 
the unemployable is always present, and apropos of this the 
board approved a resolution passed by the parish of 
Paddington urging on the Local Government Board the 
necessity of speedy legislation for the establishment of 
“ labour colonies ” on the lines of the Swiss system. 

The Manchester Crematorium. 

The annual meeting in connexion with the Manchester Cre¬ 
matorium was held yesterday. The report states that in the 
year 104 cremations took place and that there was a profit of 
£100. The chairman said that the late Bishop Fraser, Bishop 
Moorhouse, and Dr. Knox, the present Bishop of Manchester, 
all approved of cremation. The secretary Baid he thought 
that the movement was retarded by the conditions of the 


Cremation Act, 1902. and suggested that the whole of the 
crematoriums in England and Scotland should join together 
and see if the; could not get the rules and orders altered, 
such rules not being required in cases of ordinary burial. 
The precautions alluded to were, of course, intended to be 
safeguards against crime, but if they can be made less 
inconvenient and yet effective safeguards no one would be 
likely to object. The suggestion of the secretary was 
.adopted and he was asked to write to the authorities of the 

Dec. 31st, 1907. _ 


(From our own Correspondent.) 

Liverpool Education Committee: Medical Inspection of 
School Children. 

The chairman of the education committee of the city 
council at its meeting on Dec. 23rd last moved the adoption 
of the report of the special medical inspection of school 
children subcommittee, which had expressed the opinion that 
the work of inspection could best be carried out under the 
immediate control of the education committee, and recom¬ 
mended that a special medical officer should be appointed for 
the purpose at a salary of £4C0 per annum. The subcom¬ 
mittee's intention was to take the medical officer of health 
into consultation but to retain the control itself. It did 
not wish to clash with any other corporation committee and 
according to the chairman of the education committee 
they had no desire to override the work which Dr. E. W. Hope 
had already done outside the schools and they desired that that 
work should still be continued. Alderman Salvidge opposed 
the recommendation on the ground that it would create a 
new department, whereas it had not yet been proved that 
the present health authority was unable to carry out the 
extra duties suggested. He moved that the recommendation 
should be referred back to the subcommittee in order that an 
opportunity might be afforded it of discussing the matter with 
the healtli committee. The amendment having been duly 
seconded was agreed to. 

Liverpool School of Tropical Medicine: The Prevention of 
Yellow Fever. 

A despatch has been received by the secretary of the 
Liverpool School of Tropical Medicine from the Foreign 
Office respecting the presentation of the Mary Kingsley 
medals conferred by the school upon Senator Professor Golgi 
(Italy), Dr. Charles Finlay (Cuba), Professor Danielewsky 
(Russia), and Professor Theobald Smith (United States). 
The despatch was accompanied by a translation of a lengthy 
report from the Official Gazette of the Republic of Cuba of 
the ceremony at which the medal was handed to Dr. Finlay, 
the discoverer of the mosquito theory of yellow fever, by the 
Provisional Governor of Cuba. The ceremony took place at 
the great ball of the University oi Havana in the presence of 
a distinguished gathering, and the speeches delivered 
were so interesting that some are worth reproducing at some 
length. The Hon. Charles E. Magoon, Provisional Governor 
of Cuba, presided, and in handing the medal to Dr. Finlay, 
said: “An important foreign scientific institution, the 
Liverpool School of Tropical Medicine, in recognition of the 
eminent services rendered by Dr. Charles Finlay in his 
devotion to the cause of science, which culminated in his 
discovery of the agent by which the yellow fever germ is 
transmitted, has conferred upon him the Mary Kingsley 
memorial medal. This medal was designed upon the 
death of the famous African traveller, whose name 
it bears, in commemoration of her labours in the 
tropics, to be bestowed upon those persons who may 
have distinguished themselves in special work and re¬ 
searches in tropical medicine, and has been received by 
the Government of Cuba from the Minister of His Britannic 
Majesty with the request that it be officially handed to Dr. 
Finlay.” The Rector of the University having addressed Dr. 
Finlay, the latter replied thanking the speakers, the 
University, and the Liverpool School of Tropical Medicine. 
Referring to the Liverpool school he said: “ I wish 

more especially to return thanks to the Liverpool School 
of Tropical Medicine for the honour they have done 
me in conferring upon me the Mary Kingsley memorial 
medal. The honour is shared with Colonel W. 0. 
Gorgas of the United States Army. The same distinction 
has also been bestowed upon Manson, Laveran, Ross, Koch, 

and others who in different parts of the world are associated 
with the labours of the school founded by the mercantile 
community on the banks of the Mersey.” 

Deo. 31st. 1907. _ 


(From our own Correspondents.) 

Homing in Swansea. 

The Swansea corporation has decided, upon the recom¬ 
mendation of the housing committee, to erect 55 houses at 
a cost of £180 each, to be let at a rental of 5< 6 d. weekly, 
and 44 double tenement hoi sts at a cost of £300 each, to 
be let at a rental for each tenement of 4*. 6 d. weekly. 
Arrangements are in progress for holding an exhibition of 
cottages and a conference oa the 1 ou-ing qn»>-tion in 
Swansea under the auspices of the National Housing Council. 
The corporation is the owner of several large plots of land 
in the town and it is probable that one or more of these may 
be utilised for the purposes of the exhibition. 

An Asylum for Swansea. 

Since the establishment of the county asylum at Bridgend 
that institution has been available for patients resident in 
Swansea. The rapid growth of the county of Glamorgan 
led the asylum committee to give notice first of all to the 
Cardiff corporation and later to the corporation of Swansea 
to terminate the then existing arrangements and to provide 
separate accommodation for the needs of the two towns. 
Unsuccessful efforts have been made to make arrangements 
for sending Swansea patients to the asylum at Talgarth, 
which is owned jointly by the county councils of Brecon and 
Radnor, and it appears now to be probable that suitable 
accommodation will be provided by the erection of a building 
in the borough of Swansea upon land already in the 
possession of the corporation. Merthyr Tydvil having 
become incorporated will also have to sever its connexion 
with the county asylum and a suggestion has been made 
that the corporations of Merthyr and Swansea might advan¬ 
tageously combine for asylum purposes. There are over 300 
Swansea lunatics at Bridgend and about 200 from Merthyr. 

The Cardiff Mental Hospital. 

It is expected that the Cardiff Asvlum, or, as it is officially 
designated, the Mental Hospital, will be ready for occupation 
in about three months’ time. The equipment of the institu¬ 
tion is very complete and has been carefully thought out— 
so carefully, indeed, that the committee of the corpora¬ 
tion concerned with the erection of the buildings has had 
to stand a great deal of adverse criticism on account 
of the cost which has been incurred. This criticism 
has hitherto had but little effect in preventing the accom¬ 
plishment of what was really necessary. With such an 
excellent record it is difficult to understand the attitude of 
those members of the committee who have been able 
successfully to postpone the erection of an isolation hospital. 
In the original scheme this building was provided for at an 
estimated cost of about £3000. and although the medical 
superintendent (Dr. E. Goodall) expressed the opinion that 
the cost need not exceed £2000 it has been decided by 
4 votes to 3 to postpone the erection of this building until 
a future date, presumably until an outbreak of some 
infections disease has occurred which will prove its 
necessity. The majority of the members of the committee 
were evidently influenced in their decision by a report pre¬ 
sented to them showing that although most of the asylums 
in this country were provided with isolation hospitals they 
were very rarely used. In spite of this it is quite certain 
that the Commissioners in Lunacy will quickly draw the 
attention of the committee to the absence of this very 
necessary accessory to every well-ordered asylum. 

Dec. 31st, 1907. _ 


(From our own Correspondents.) 

St. Mungo's College. 

The Faculty of Medicine of St. Mungo's College has pre¬ 
sented a memorial to the governors of the College in which 
it states its views as to what should be done in order to 
insure the prosperity and even the existence of the College. 

60 The Lancet,] 


It is the unanimous opinion of the Faculty that the only solu¬ 
tion of the present difficulty lies in maintaining a complete 
medical school in connexion with the College with classes 
covering every subject in the curriculum. It points out 
that it was the absolute necessity of a proper supply of 
students for the wards of the Royal Infirmary that caused 
the Royal Infirmary Medical School to be brought into 
existence by the managers and this also constitutes the 
reason why the school should continue to exist in 
its entirety in the future. It is said that as a hos¬ 
pital without students the Royal Infirmary would fail to 
secure the services of the most eminent physicians and 
surgeons upon its staff, except in so far as appointments at 
the Royal Infirmary might be regarded as stepping stones to 
similar positions at the Western Infirmary. It has been 
generally admitted that in the interests of the Royal 
Infirmary it is eminently desirable that its own medical 
school should be adequately endowed and affiliated to the 
University of Glasgow, and it was for the accomplishment of 
this purpose that the affiliation section was introduced into 
the Universities Act of 1889 at the instance of the managers 
of the Glasgow Royal Infirmary. In our opinion (says the 
memorial) affiliation is the only solution of the difficulty. As 
to the sum necessary to enable the governors to seek affiliation 
it is for the Universities Committee of the Privy Council to 
fix this; the University itself has no say in the matter. 
In this connexion, however, it is pointed out to the 
governors that prior to the absorption of the Queen Margaret 
College for Women by the University the University Court 
passed a resolution in favour of the actual affiliation of that 
College, the endowments of which amounted to between 
£40,000 and £50,000 in addition to the buildings. The 
memorial then goes on to deal with the probability of 
University students voluntarily attending their later classes 
at the Royal Infirmary if their earlier classes were taken at 
the University. The University has no power to compel any 
of its students to study in the Royal Infirmary wards, and 
the St. MuDgo’s Faculty is of opinion that no means short 
of compulsion would secure Euch attendance by men who 
have for three or four years been attached to another 
teaching centre. Attention is drawn to the fact that the 
experiment of sending students to other institutions for their 
earlier studies was actually made by two of the London 
schools and this experiment resulted in failure. 

7 he Medical Profession and Notification of Births in Bhugom. 

A deputation representing the medical profession in 
Glasgow waited on the health committee of the town council 
last week to explain the attitude of the profession towards 
the Notification of Births Act which the corporation has 
decided to put into operation in the beginning of the year. 
The medical men of the city already, through a deputation 
when the omnibus Bill was under consideration last spring, 
assured the corporation of their entire sympathy with the 
object of the Bill, namely, the reduction of the infantile 
mortality amongst the poorer and less informed classes of 
the community. They are now of opinion, however, that 
the means by which this object is sought to be attained 
in the Notification Act, in the form In which it has 
emerged from Parliament, are clumsy and in certain 
respects of a highly objectionable character. The deputation 
urged that to make notification compulsory for the medical 
man would be contrary to the obligations of the medical 
oath. It was further pointed out that the cases with which 
the Act was intended to deal were not for the most part 
attended by medical men. This fact was illustrated in recent 
reports by the medical officer to the corporation, in which he 
showed that in the Cowcaddens district of the city, for 
instance, in which the infantile mortality is deplorably high, 
there was no medical man present in 76 percent, of the births 
investigated. The medical profession in Glasgow propose 
in the case of each birth in connexion with which they are 
called in to place in the hands of the father or other 
responsible person a simple form of notification with 
directions for its transmission to the medical officer of health. 
The deputation concluded by asking the corporation without 
adopting any resolution on the subject to accept such notifi¬ 
cation as falling within the scope of the exemption clause of 
the Act, which provides that no person Bhall be liable to a 
penalty if he has reasonable grounds to believe that notice 
has been duly given by some other person. 

Crathie and Braomar Parish Council: Medical Officer ship. 

At the first meeting of the newly elected parish council of 

[Jan. 4. 1908. 

Crathie and Braemar held on Dec. 13th, 1907, it was moved, 
in regard to the uppointment of a medical officer— 

That in the opinion of the majority of the council the appointment 
of the present medical officer was irregular; that three months’ notice 
of dismissal be given and the usual steps taken for the filling of the 

Objection was made to the motion that it was incompetent, 
out of order at the meeting, and at the best only based on a 
matter of opinion. It was also pointed out that at the date 
of the appointment referred to a copy of the minutes and all 
particulars connected were forwarded by the clerk to the 
Local Government Board and that the clerk received con¬ 
firmation of the appointment. The motion was carried by 
6 votes to 2. 

Perth Royal Infirmary: Reconstruction .^oheme. 

The subscriptions towards the reconstruction scheme for 
Perth Royal Infirmary now total £14,601. 

Dec. 31st, 1907. _ 


(From our own Correspondents.) 

Lord Kelrin. 

Very great sorrow in Belfast was felt at the announce¬ 
ment of the death of Lord Kelvin who was born in Bdfast 
in a house still existing in College-square East (No. 18), at 
present occupied by a member of the medical profession. 
Lord Kelvin’s father, Dr. James Thomson, came originally 
from Ballynahinch, in county Down, and was professor of 
mathematics in the old Belfast Academical Institution. He 
wrote a famous book, “Thomson’s Arithmetic,” long 
popular in Ulster, and he was afterwards professor of mathe¬ 
matics in the University of Glasgow where Lord Kelvin 
studied before going to Cambridge. 

The Tuberculosis Exhibition. 

On Dec. 17th, 1907, in the presence of a large audience, Her 
Excellency the Countess of Aberdeen opened the Tuberculosis 
Exhibition in Lurgan and formed the Lnrgan and Dis¬ 
trict Branch of the Women’s National Health Association of 
Ireland. On the 18th Sir John Byers gave a lecture on Why 
Tuberculosis is so Common in Ireland: on the 19th Dr. 
John McCaw lectured on Tuberculosis in Children ; on the 
20lh Professor W. St. Clair 8ymmers gave an address on the 
Germ of Tuberculosis and some of its Effects; and on the 
21st Professor Mettam, F.R.C.V.S., lectured on Tuberculosis 
in Animals. There were immense audiences and the great 
success of the tuberculosis exhibition in Lurgan is due to 
the unceasing exertions of Dr. Samuel Agnew, medical 
officer of health of Lurgan. 

Hospital Medical Reports. 

It is always pleasant to record the publication of medical 
reports by hospitals, for they save much valuable material 
from oblivion. The lateBt hospital to publish its records 
is the Ulster Hospital for Children and Women and Dr. 
H. H. B. Cunningham is acting as editor. The first 
issue contains an article by the same gentleman on 
Adenoids ; one on Hsematuria due to Cystic Kidney, by 
Mr. A. B. Mitchell ; one on Cancer of the Uterine 
Cervix by Dr. Marion B. Andrews; one on Congenital 
Lymphangeioma by Mr. Howard Stevenson ; and the report 
of a fatal case of Cerebro-spinal Meningitis complicated by 
Parturition. We wish these records a successful and long- 
continued future. 

Dec. 31st, 1907. 


(From our own Correspondent.) 

The Differential Tuberculin Reactions. 

At a recent meeting of the Budapest Royal Society of 
Medicine Dr. Lfiszlo Detre, privat-docent at the University of 
Budapest, delivered an address on the Differential Tuberculin 
Reactions. He said that these reactions were of assistance 
in various ways in the investigation of the biology of 
tuberculous infection. The researches which he had carried 
on aimed at the elucidation of the etiology of tuberculosis 
and the discrimination of a fresh case from an old one. Of 
late years two questions have received much attention from 
pathologists—namely, (1) Has the bacillus of bovine 

Tb* Lancet,] 


[JAN. 4, 1908 . 61 

tuberculosis any power of producing human tuberculosis ? 
and (2) Is it possible to distinguish the bovine bacillus from 
the human one so as to recognise which infection is present 
in a given case 1 The dnalistic theory originated with Fro. 
fessor Robert Koch who asserted that bovine tuberculosis 
and human tuberculosis were quite distinct from one another. 
There was now positive evidence that these two infections 
were caused by two kinds oi bacillus which although standing 
very near to each other could nevertheless be distinguished 
by certain signs. It was to the investigations of English 
and German physicians that the knowledge of these facts 
was chiefly due. The statement of Spengler that the two 
kinds of bacilli could be distinguished under the microscope 
when stained in a certain manner was not yet verified. A 
constant difference could be shown in the alkalinity of the 
bouillon culture of the two bacilli (Smith). An important 
difference between them was that the bacillus of bovine 
tuberculosis was much more virulent for mammalian animals 
than the human bacillus was. One milligramme of a culture 
of the bovine bacillus injected into a vein of a tame hare 
killed it within about three weeks, while several months 
were required for a culture of the human bacillus to kill a 
similar hare. By means of these differences it was possible 
to decide whether a given case of tuberculous infection in 
the human subject was caused by one or the other or by 
both types. 

Up to the present time there were 20 cases known in 
which the bacilli were of the bovine type. In these cases 
the cnltures were mostly obtained from the mesentery of 
children suffering from abdominal infection. Bovine bacilli 
had also been found in one or two cases of tuberculous 
meningitis and consumption. The difference between the two 
bacilli was so marked that Weber succeeded in cultivating 
both bacilli in one and the same case. No method has yet 
been discovered by which it would be possible to determine 
the type of bacilli present in a living subject. Dr. Detre has 
therefore endeavoured to draw some inference as to the 
nature of the infection from differences in the sensitiveness 
of the infected organism against the poisons of the two bacilli. 
It was known that tuberculous animals reacted strongly to the 
poison of the tuberculosis bacillus and that they reacted in a 
less degree to the poison of bacilli resembling the tuberculosis 
bacillus, though differing from it by their acid-resisting 
property. The reaction manifested itself partly in local and 
partly in general thermal and organic changes. It might, 
therefore, be assumed that the organism was most sensitive 
against the poison of the bacillus which had caused the 
infection. On the ground of this assumption Dr. Detre has 
compared the sensitiveness of some persons against the two 
kinds of tuberculous poison. In these observations he used 
the filtrate from bouillon cultures of the two bacilli—i.e., the 
human and the bovine bacilli. He did not use tuberculin, 
because Koch’s tuberculin did not contain all the poisons 
of the bacilli. 

Tuberculin and the filtrate were not chemically 
identical and there were also some striking physio¬ 
logical differences between them. In early cases of 
tuberculosis Dr. Detre has found that there was an 
intense sensitiveness against the filtrate ; and he has 
observed individuals who reacted to the Tooo’oooith of a 
centigramme of the filtrate, the Bymptoms being stroDgly 
marked local (edema and a rise of temperature amounting to 
0*3° or 0 4° C. On the other hand, it was known that with 
Koch’s tuberculin such small quantities never produced such 
a reaction. He therefore inferred that the filtrate contained 
an unstable, easily decomposing poison, which might serve 
to distinguish the two kinds of infection. His procedure 
consisted in giving to tuberculous patients subcutaneous 
injections of the filtrates from cnltnres of human and bovine 
bacilli in the same degree of dilution. He then observed 
which substance and in wbat concentration produced local 
reaction. When he injected in one arm of the patient the 
filtrate of the human bacilli and in the other arm the filtrate 
of the bovine bacilli considerable hypersensitiveness against 
the human filtrate could be seen. The differences between 
the effects of the two injections were sometimes very 
striking. For instance, on one side a given dilution, say 
1 in 100,000. gave no reaction at all, whilst on the other side 
there was an infiltration of the size of a penny or even larger. 
With some individuals the reaction to the bovine bacillus 
was stronger than the reaction to the human bacillus—a fact 
which proved that the deviations were produced not only by 
quantitative differences in the fluid injected but also by 
direct specific qualitative differences. In the course of 

these investigations it happened that Pirquet announced his 
discovery of the so-called “allergic reaction." The basis of 
this reaction is the “allergia”—that is to say, the changed 
capability of the organism with reference to reaction. He 
discovered that persons who had once suffered the effects of 
the poisons of the bacilli tuberculosis—that is to say, who 
had withstood a tuberculous infection or were at the 
time of observation still infected with tuberculin—showed 
the so-called cutaneous reaction if tuberculin was scratched 
into their skin, while, on the contrary, the skin of a normal 
person did not react at all to tuberculin. 

Having read about this discovery which Pirquet published, 
Dr. Detre at once proceeded to verify the results which 
he had already obtained with the cutaneous reaction. 
For this purpose he used concentrated and diluted 
solutions of Koch's tuberculin, Deny’s tuberculin, and 
Spengler’s human and bovine filtrate, and finally, for 
the sake of comparison, carbolic acid solution of 0 5 
per cent, strength, all according to the method of 
Pirquet. The first observations have already shown 
that the results of the cutaneous reactions entirely corre¬ 
sponded with those of the previously performed sub¬ 
cutaneous reactions, for persons who reacted t.o the sub¬ 
cutaneous injections of the filtrate of human bacilli gave 
a stronger reaction to the same filtrate also by the skin 
inoculation. These observations have also shown that 
the reactions had a quantitative Rvalue inasmuch as the 
diameter of the local reaction was in direct ratio to 
the dilation of the Koch tnbercnlin. Besides this the 
prevailing filtrates gave always stronger local reactions 
than the ten-fold dilution of Koch’s tuberculin that was of 
the same concentration as the filtrate. This fact supported 
the assumption that the filtrate contained thermolabile toxins 
which Koch’s tuberculin had lost daring the process of pre¬ 
paration. One considerable drawback to the Pirquet reaction 
was that the great majority (90 or 95 per cent.) of adults 
gave it positively. From this it could be easily understood 
that it was of no considerable valne. Dr. Detre has inves¬ 
tigated whether there were any differences in the size of 
the local reaction according as the case was recent or of long 
standing, and his inoculations have shown that fresh cases 
were distinguished from old ones by the former having a 
greater sensitiveness to the filtrate. It was an open question 
whether there was any constant difference (caused by various 
degrees of sensitiveness to the poison) between the reaction 
of the Koch tuberculin and the filtrates. For elucidating 
this Dr. Detre has carried out special investigations in which 
he used (1) Koch’s tuberculin in a concentrated form ; (2) the 
filtrate from human bacilli ; (3) the filtrate from bovine 
bacilli ; and (4) the comparison solution of carbolic acid. 
These observations have Bhown that the single infections 
could be classified according to certain types of reactions. 
In the recent progressive cases, sensitive to the bacterial 
poisons, the local reactions following injections of the filtrate 
were larger than, or equal to. or nearly as large as the 
local reactions due to tuberculin. In chronic cases the 
reaction after the injection of the filtrate was inferior to that 
produced by Koch's tuberculin as regards size. Finally, in 
inveterate or very extensively spread cases the reaction 
might be entirely negative. This fact has been already 
mentioned by Pirquet. 

The explanation of this difference was that the 
energetic reaction of the fresh cases was caused by 
their sensitiveness to the poison ; at a later period the 
organism became tolerant of the labile poison and It 
was sensitive only to the protein ; finally, it lost its 
sensitiveness even to the protein. In the investigations 
conducted by Dr. Detre the differences between the human 
and bovine infeotions were clearly shown in the local reac¬ 
tions produced by the two filtrates. He bad some cases 
in which the local reaction due to the bovine bacillus had a 
diameter of 1 5 millimetres, whilst the local reaction due to 
the human bacillus had a diameter of 12 millimetres. On 
the other hand, there weTe cases, though fewer in number, 
in which the local reaction due to the human bacillus was 
considerably surpassed in size by the reaction due to the 
bovine bacillus. This fact proved that there were not only 
quantitative differences in certain cases. It was a general 
law of immunity that the organism reacted most distinctly 
to substances provoking the immunity. And because the 
allergio reaction was an immunity reaction it was very prob¬ 
able that the cases of bovine reaction were caused by the 
bovine bacillus and the cases of human reaction were 
caused by the human bacillns. In a certain number of cases, 

62 The Lancet,] 


[Jan. 4,19C8. 

however, there were no appreciable differences between the 
two reactions ; in these cases Dr. Detre assumed that the in¬ 
fection was “ mediated ” by both bacilli. He did not consider 
that one bacillus wsb the infecting agent and that the other 
only accompanied it; he held this opinion because there were 
cases in which besides the great sensitiveness against one 
species there was no sensitiveness at all against the other. 
The infection might take place in the following manner—a 
view which is also taken by Professor Behring. Duiing 
infancy a child became infected with the bovine bacillus 
through taking milk, butter, &c., and this bovine infection, 
if it was not entirely recovered from, created a predisposi¬ 
tion to the human infection contracted at a subsequent 
period by inhalation when sensitiveness against both species 
developed in the doubly infected diseased organism. 

Dec. 20th, 1907. _ 


(From our own Correspondent.) 


It is reported that malarial fever is raging at Smyrna and 
Konieh. The epidemic is attributed to the many swamps and 
marshes which are to be found almost everywhere in the 
above localities. From Konieh comes an urgent demand for 
a medical man, but the authorities of the medical school in 
Constantinople think that medical skill will be of very little 
use if the source of the epidemic—namely, the marshes—is 
not removed. The municipal authorities of Konieh have, 
however, been informed that a medical man will be sent to 
the affected districts. In connexion with this subject the 
Turkish newspaper Sabah publishes some details concerning 
the irrigation of the plain of Konieh and the drying up of 
its marshy places which are of medical interest. The 
schemes proposed for carrying out the work have been 
approved by the Council of Ministers and sanctioned by the 
Sultan. Large areas of land will be rendered capable of 
cultivation and the Anatolian railway, which is now carried 
as far as Boulgourlou, will shortly reach Adana, the line 
everywhere traversing fertile land. The water required for 
irrigation is to be supplied by Lake Beyshehir, situate 
about 100 kilometres to the west of Konieh. Two small 
streams, the Beyshehir Sou and Tcharshembe Sou, which 
provide an escape for the overflow of the lake, are to be 
canalised and controlled for a distance of about 145 kilo¬ 
metres. A canal of 30 kilometres will be built round the 
marshy depression at Karaviran, known as the Sogla Gol, 
and another canal of 20 kilometres will connect the two 
above-mentioned streams in the narrow Valikova Pass. 
Several barrages and three large reservoirs will also be 
necessary, as well as an aqueduct and innumerable small 
canals for the distribution of water for irrigation purposes. 
It is estimated that it will be possible to supply 600,000 
“deunums" with water; in other words, 132,500 acres of 
land will, it is hoped, now be brought under cultivation. 
Through this scheme it is expected that not only will the 
irrigated places produce annually grain of excellent quality 
sufficient to load at least 20,000 railway wagons but also 
that in consequence of the drying up of the marshes they 
will cease to be a source of malaria. 

The Italian Hospital. 

A service of gratuitous consultation and surgical treatment 
has been opened in the above hospital by its newly appointed 
surgeon, Dr. A. de Fabii, who has just arrived from Italy. 
He was surgeon to the principal hospitals of Rome and it is 
expected that he will be able to do much good work in the 
Turkish metropolis. The gratuitous operations will be 
performed daily from 9 to 11 A M., excepting Mondays and 

Cases of Extraordinary Longevity. 

The Stamboul newspapers assert that no other country 
produces so many cases of extraordinary longevity as does 
the Ottoman Empire. Not all the cases brought before the 
attention of the public are genuine or credible, but, on the 
other hand, an individual is occasionally found whose 
remarkably great age is proved by substantial testi¬ 
mony. The following case seems to be genuine. At Yeni 
Bagbtckd, Stamboul, there resides a certain Hadji Raif 
Effetdi who is 124 years old and who has been the book¬ 
binder of the Military School of l'ancaldi for the past 80 
years. This man’s father died at the age of 142 years. He 

was named Edhem Pasha and was a Government official. It 
seems that in Russia centenarians are also found. It is 
reported (this time it is the Levant Herald that is responsible 
for the news) from Revel in the Baltic Provinces that an 
Esthonian lady, born in 1783, and therefore aged 124 years, 
has just thought it about time to make her will in case 
“ anything should happen.” The old lady, who was born in 
the reign of Catherine II., has thus lived in the reigns of seven 
of the eight Tsars belonging to the house of Komanof- 
Holstein whose sway dates from 1762. 

Dec. 24th, 1907. _ 


(From our own Correspondent.) 

Winnipeg General Hospital. 

The city council of Winnipeg has decided to grant the 
request of the hoard of governors of the Winnipeg General 
Hospital to raise the annual grant from $30,000 to $40,000. 
The former grant had been fixed on the basis of the work 
done in 1904, but since that time the number of city patients 
has increased 40 per cent. Last year the hospital under¬ 
took several absolutely necessary improvements and addi¬ 
tions caused by the great increase in its work. This 
involved an expenditure of $160,000 and so far the city 
has paid $125,000 of this amount. For the first time 
in the history of the hospital it was unable to pay 
its monthly accounts in October. These amount to 
about $13,000 per month. The board of governors also 
asked that the hospital be granted by the city 325,000 
at once on debenture account to close out the accounts 
incurred by building operations last year. They aho asked 
that legislation be obtained to provide for the immediate 
erection of a proper mortuary and a place for holding 
inquests, post-mortem examinations, kc. ; also a proper 
pathological department. Winnipeg requires a new isolation 
hospital; and the board requested that it be erected and 
conducted by the city and so relieve the General Hospital 
of the work of taking care of cases of infectious diseases. 
The cost of such a hospital for Winnipeg is placed at 
8150,000. It should accommodate from 80 to 100 patients 
and have provision for from 40 to 50 tuberculous patients. 

Toronto Hospital for Incurables. 

The annual meeting of the board of management and 
patrons of the Toronto Hospital for Incurables, formerly 
called the Toronto Home for Incurables, took place recently. 
Dr. Bruce Smith, the Ontario Government inspector of such 
institutions, was present and said that of ail similar institu¬ 
tions both in Canada and in the neighbouring country of the 
United States which he bad visited none could surpass the 
state of this hospital. He also pointed out that the grant 
of the Ontario Government of .$5323 and that of the city 
of Toronto of 84000 were totally inadequate when the 
importance of the work was considered. The secretary pre¬ 
sented the annual report and showed that during the past 
hospital year 176 persons had been cared for. On Oot. 1st, 
1906. patients numbering 139 were registered, and to that 
number 37 were added during the year. The deaths in the 
same period totalled 31 ; four patients left and there were now 
in the institution 141. There are 80 patients supported 
at present absolutely free of cost ; 18 pay a nominal 
amount for maintenance. The present year’s work was 
carried on with the small deficit of $486. The average 
cost of each patient was 66 cents per day. 

Alexandra and St. Paul's Hospitals, Montreal. 

These two hospitals in the city of Montreal look after 
respectively the cases of infectious and contagious diseases 
occurring amongst the English- and French-speaking popula¬ 
tion of that city. The first arrangement for tbe mainten¬ 
ance of these made with the city called for a grant to each 
of $15,000 per annum, but it has been found that almost a 
doubled grant would just about be adequate to continue their 
work. A new agreement Is now required from the city 
council. It is asked that each be granted 85000 for the 
balance of the presentyear and that on Jan. 1st next the total 
grant to each be 325,000, this agreement to last for a term 
of three years. The hospitals then agree to treat all 
patients without regard to religious denomination who may 
be sent to them by the city in such numbers as the said 
hospitals can accommodate, each accommodation not to be 

The Lancet,] 


[Jan. 4,1908. C3 

for less than 100 patients per day. In case of an epidemic 
the city will be allowed to use all the beds for the treatment 
of cases of one contagions disease only. 

Montreal Maternity Hospital. 

The sixty-third annual meeting of the friends and 
supporters of the Uontreal Maternity Hospital was held 
recently in that city, Dr. T. G. Roddick being in 
the chair. In making a short address Dr. Roddick stated 
that the building was now practically free from debt 
owing to the energy of the ladies of the governing body and 
two or three good donations and bequests. The endowment 
fund was increasing gradually and now amounted to §6000. 
During the last hospital year 370 married women had been 
treated in the institution, and the report for the present year 
showed that the number had reached 440 Private patients 
had nearly doubled while the number of the unmarried 
patients had not increased. The hospital had conducted its 
financial affairs successfully during the year and there was a 
credit balance in the bank of §356. 

A Simple Staining Method for the Gonococcus. 

In the Dominion Medioal Monthly Dr. J. G. Fitzverald and 
Dr. E. H. Young of the Toronto Hospital for the Insane give 
a preliminary note on the above subject. It is simple and 
has been found useful by them and, as they state, must 
appeal to the busy general practitioner. The gonococcus is 
stained by an aniline basic dye and is decolourised by Gram’s 
method. Their method is simply the application of Nivel's 
soapy methylene-blue solution without any connter-stain, the 
volution being made as follows: methylene blue B. patent, 
3 ’75; Venetian soap, 175; and distilled water, 1000. The 
smears, which should be made on slides (and care must be 
taken to have them as thin as possible), are fixed in the air 
and then stained (without heating) for one minute with 
Nissl’s solution, washed, blotted, and are ready for examina¬ 
tion with the oil-immersion lens. 

Is Toronto to Have a Nerv Medical School ? 

McMaster University is a denominational institution in 
Toronto belonging to the Baptists. At a recent Baptist con¬ 
vention held at Woodstock the board of governors and Senate 
of McMaster University submitted to that convention a 
report recommending the project of establishing a medical 
faculty in connexion with that university. The University 
of Toronto, with which McMaster University is not affiliated, 
has a strong medical faculty, their freshmen numbering this 
year about 230. Probably McMaster University considers 
this is too large a class even of freshmen for one university 
to handle successfully and that it could attract to itself a 
considerable proportion of.the medical student body attached 
to the Provincial University. However, as yet no definite 
steps have been taken along the lines suggested by the Senate 
and board of management of McMaster University. 

Dec. 20th, 1907. _ 


(From our own Correspondent.) 

A Centralised Ambulance System. 

Although New York was the first city in this country to 
adopt the army ambulance as a means of conveying the sick 
in civil practice there has never been a well-organised system 
of ambulance service. Each hospital has bad its own 
ambulances and the police officials have summoned them in 
cases of emergency. The police authorities have created 
districts for the different hospitals to which the ambulances 
of that hospital have been limited, except on occasions of 
great emergencies. The Municipal Hospital Commission 
recently devoted a session to conferences with representatives 
from the various hospitals for the purpose of obtaining 
information in regard to the working of the present system. 
The conclusion was that there should be a central ambu¬ 
lance station corresponding to the fire headquarters 
to which all ambulance calls should come and through 
which they should be assigned to the various hospitals. 

Flies the Cause of High Summer Mortality. 

The Merchants’ Association Committee on Pollution of the 
Waters has published the report of the bacteriologist of the 
Water Bureau of New York city on investigations to deter¬ 
mine the influence of river Hies in conveying the germs of 
disease to the people of the city. It appears that a large 
number of fiy-traps were placed underneath the piers of the 

city which were daily visited and the flies collected and sub¬ 
mitted to examination by counting and the best bacterio¬ 
logical methods. The examination Bhowed that a “South 
Street housefly” carried 100,000 bacteria. At the same 
time a careful investigation was made of the sanitary 
condition of the water front of the entire city. It was 
found that sewage abounded and that those flies were 
thickest at the point where there was the most sewage 
and that where it was scarce the flies were few in 
number. The flies were found to carry less bacteria in 
the early season than during the hot term. The tabula¬ 
tions and diagrams of the report show that the time of 
the greatest prevalence of flies in 1907 was the three 
months beginning July 1st and ending Oct 1st. A record of 
the deaths from intestinal diseases shows that the deaths 
from these diseases rose above the normal at the time at 
which the flies became prevalent, culminated at the same 
high point, and fell off at the time of the gradual falling-off 
of the prevalence of the insect. The report concludes with 
the assertion that this so-called harmless insect is one of the 
chief sources of infection, which in New York city causes 
annually about 600 deaths from typhoid fever and about 
7000 deaths yearly from other intestinal diseases. 

The Plague on the Pacific Coast. 

It appears from a report of a commission acting under the 
authority of the American Medical Association that the 
plague has not been exterminated from the Pacific coast. 
Since August 108 cases have been verified, of which 65 died. 
There was in addition a large number of suspected cases. 
The first recognised case occurred in 1900, but suspected 
cases had from time to time been previously reported. The 
effect of the great fire following the earthquake seems to have 
been to extend the disease by scattering tbe rats and the in¬ 
oculation of ground squirrels, though an enormous number of 
rats were killed in the fire. Another feature of tbe fire which 
increased the Bpread of the plague was the insanitary con¬ 
ditions which followed. The commission states that the 
sewer system was almost completely broken up, water was 
scarce, people were compelled to cook and almost to live in 
the streets, garbage was thrown about promiscuously, refugees 
were crowded together in tents and later in shacks, and these 
camps became filthy. Some of these camps are said to have 
become hives of dirty humanity and to have swarmed with 
rats and fleas. That the plague is now widely scattered 
among the cities of the Pacific coast is evident and the 
measures taken to arrest and exterminate it seem altogether 
inadequate owing to the indifference of the people and the 
local authorities outside of San Francisco and Oakland where 
thorough anti-plague work is being done. The commission 
concludes that tbe continued existence of such a disease over 
such an area, and for the time during which it is evident 
that the infection has existed here, would seem to make the 
infection a subject for national consideration. 

State Prohibitum of Nostrums. 

Tbe State of Massachusetts, through its board of health, is 
rigidly enforcing its laws against the sale of noxious 
nostrums, one of the most conspicuous of which is cocaine 
in various forms. The law, which went into effect on 
Sept. 1st, 1906, provides— 

That It shall bo unlawful for any person (Including physicians) to 
sell or to expose or offer for Bale or to give or exchange any patent 
or proprietary medicine or article containing cocaine or any of its salts 
or alpba-eucain or beta-eucain or any synthetic substitute of the 

A large number of preparations, generally advertised as 
remedies for catarrh or diseases or the throat, have been 
condemned by the board of health, and their proprietors 
brought into court and convictions obtained, i he effect of 
this law in the suppression of these injurious and often 
dangerous nostrums has awakened a wide spread interest and 
other States are certain to take similar action. 

Titleroulosis in Herds of Cattle. 

The New Y’ork State Veterinary College reports through 
its expert bacteriologist that 72 per cent, of the herds of the 
State of New Y'ork are tuberculous. This expert has made 
a careful study of meat inspection and states that although 
the citizens of the State are now thoroughly protected against 
Chicago and Western beef by the pure food and meht 
Inspection laws, the markets of the State are loaded with 
domestic beef, a large percentage of which is in'ected with 
the tuberculous germ. The statistics collected by Professor 
Moore show that of 364 herds examined 72 ■ 3 per cent, 
included tuberculous animals. Estimates based on these 

64 The Lancet,] 


[Jan. 4, 1908. 

statistics show in his opinion that of the 1,800,000 milch 
cows in this State 440,000 are infected with tnbercnlosis. 
The disease is constantly spreading throngh the traffic in 
cattle. The remedy is thorough inspection by a competent 
corps of State inspectors. 

Deo. 19 th, 1907. 


(From our Speciat. Correspondent.) 

Sanitary Reform in India,. 

The great event of the past week has been the issue by 
the Government of India to the various local governments 
of a letter on the improvement of the sanitary services in 
India. It is contemplated to employ a greatly increased 
number of medical officers of health as well as of sanitary 
inspectors, and more sanitary boards will also be created. 
There is not a word, however, regarding legislative 
powers which are at present very deficient, or as to 
how the expenses of sanitary improvements have to 
be met. Money is wanted badly by every municipality 
for public sanitary schemes but the difficulty in effecting 
improvements is still greater in the case of private indi¬ 
viduals. It is hardly recognised sufficiently that the 
sanitary evils chiefly pertain to the home, and to enforce 
measures of sanitary improvements in the case of private 
individuals is often a very serious hardship and perhaps as 
often an impossibility. The great mass of the people are 
poor and their unhealthy surroundings are largely due to 
their poverty. That more executive officers are required no 
one will question, and it is satisfactory to learn that the 
tenure of their appointments will be safeguarded by the local 
governments and will not be subject to the whims and fancies 
of municipal boards. A very large field of work will be 
thrown open to Indian medical men who have been trained 
in England and have taken a degree in sanitary science. This 
is as it should be, but this concession to Indians must 
not be carried too far and the higher posts should be 
reserved for British sanitarians. A temporary medical educa¬ 
tion in England does not produce that independence and 
force of character which belong to those Englishmen who 
have had a life’s training at home, and the ingrained 
habits of life in an Indian tend to reassert themselves when 
he returns to his native country. It iB curiously asserted 
that though certain appointments will be open to European 
and Indian officers, on grounds of economy preference would 
naturally be given to Indian candidates. The principle of 
prohibiting private practice for health officers is definitely 
laid down and the pay of such officers will be determined 
accordingly. A great deficiency at present exists in properly 
trained sanitary inspectors but an arrangement is 
contemplated for instituting some form of an examining 
board. This letter of the Government marks the commence¬ 
ment of sanitary reform but it all depends upon the local 
governments as to how the proposed scheme will be carried 

A Ncrc Parti Hospital in Bombay. 

The foundation-stone of a large general hospital for Parsis 
has just been laid in Bombay. It is hardly a generation ago 
that Parsis refused to go to hospital owing to the joint 
family system prevailing. First, however, a maternity hos¬ 
pital was started and proved very successful, then a fever 
hospital was established, which was also successful, and 
now by the liberality of certain wealthy members of 
this community, more especially the Petit family, a 
magnificent hospital costing nearly 14 lakhs of rupees has 
just been commenced. It will have a magnificent, aspect 
over the sea to the west and will consist of three main 
blocks connected by corridors. The outer blocks will each 
contain 120 beds and the central one will include the 
operating theatre, the laboratory, and rooms for electrical 
and light treatment. The equipment of the hospital 
generally will be on the most up-to-date lines. In the 
operating theatre the students will be shut off from the 
actual place of operations by plate glass and the sole ventila¬ 
tion of the theatre will be through an antiseptic pump. 
Considering that the population of the Farsi community in 
Bombay city is only about 80,000 it must be admitted that 
they are making most admirable provision for their Bick. 

Fever in Bengal. 

It will be remembered that the prevalence of malariajin 
Bengal was the cause of a special committee being appointed 
last year and it has now presented its report. It 
cannot be said, however, that there is much prospect of 
success. In addition to the waterlogged condition of the 
country the main causes of fever are accredited to the in¬ 
sanitary state of the village sites. Any improvement in the 
latter direction depends largely upon educating the villagers, 
which is bound to be a very slow process. The report says 
that the value of sanitation, the prophylaxis of malaria 
by the use of quinine and mosquito curtains, and the 
efficient treatment of malaria by quinine are matters 
which might well be taught in the schools. This is not 
very promising and the use of mosquito curtains for the 
poor villagers may be said to be impracticable. The 
distribution of quinine may easily be effected, but ' the 
destruction of mosquitoes in such low country, with water 
nearly everywhere, is hopeless. A certain amount of 
improvement may be attained in a few places by suitable 
drainage but the nature of the country puts many limitations 
on this procedure. It is natural that the committee should 
lay stress on the necessity for further inquiry. The medical 
aspect of the question is to be taken up more in detail. 

Dec. 12th, 1907. 


(From our own Correspondent.) 

Patent Medicines in Australia. 

Under the existing Commonwealth law relating to the 
admission of patent medicines where a trade secret is 
involved no regulations can be framed prescribing the trade 
description unless the Governor-General considers such 
necessary for the welfare of the public. A new Bill has been 
introduced in which power is given to make a general 
regulation requiring a trade description, including disclosure 
of ingredients, for all medicines or food for infants or 
invalids, but in individual cases if the Governor-General is 
satisfied that it would mean disclosure of trade secrets and is 
not necessary for the public welfare he may allow a modified 
description. The trade description may require in the case 
of medicines a statement of the diseases or ailments which 
they are intended to cure. The practical meaning is that 
importers must show that a trade secret will be disclosed in 
order to obtain exemption from stating on bottle or packet 
its component parts. 

Melbourne Hospital Election. 

The annual report to the council of the dean of the faculty 
Of medicine in the University of Melbourne contained a para¬ 
graph referring to the method of appointing the staff at the 
Melbourne Hospital. The report suggested that a communi¬ 
cation should be made to the hospital managers pointing out 
that the University entrusts the whole general clinical training 
of its medical students to the hospital staff. "The present 
system,” the report continued, "of electing the staff is a 
disgrace to the hospital, to the medical profession, and to 
the community, and presents a bad example to the medical 
students. The Melbourne Hospital stands almost alone in 
its methods of election.” The council thereupon directed 
that the paragraph concerning the hospital should be for¬ 
warded to the President of the institution with the strong 
endorsement of the council and a request to bring it before 
the hospital committee. When brought before the com¬ 
mittee at itB last meeting the report met with a very chilly 
reception. Several members took exception to the strong 
terms in which it was worded and appeared to regard it as a 
slight upon their conduct of the institution. On the other 
band, the Rev. Dr. Marshall, a member of the committee, 
expressed the view that the language was perfectly justified. 
It is probable that reform in some lines will shortly be 
brought about but in view of the fact that the Government 
is bringing down a Charities Bill in which some proposals 
are embodied for the appointment of hospital staffs through¬ 
out the state nothing will be attempted until these provisions 
are open for discussion. 

Hospital Saturday and Sunday Collections in Melbourne. 

The annual Hospital Saturday and Sunday collections in 
Melbourne have been very successful. The total amounted 
to £6884, which is the largest sum received since 1888. Last 


[Jan. 4, 1908 65 

Thb Lancet,] 

year’s total was £6170. The movement is now very well 
organised and works smoothly. The greatest contribution 
was made bv the police whose collection through their 
band was £605. 

Women's Hospital , Melbourne. 

A fund was recently started by the Lady Mayoress of 
Melbourne for extension of buildings at the Women’s 
Hospital. It is now announced that the fund has reached 
£5000. which enables the committee to claim a further sum 
of £5000 promised by the Victorian Government. 

The Protection of Infant Life. 

The Victorian Government has introduced a Bill dealing 
with this subject. In 1901 there were 525 registered nurses 
in charge of 779 children and the deaths were 12 • 7 per cent. 
There were 69 police inspectors. In 1902 the percentage of 
deaths was 15• 1 ; in 1903,13 7; in 1904 9 7; in 1905. 7 8; 
and in 1906, with 583 nurses and 974 children, the deaths 
were 10 ■ 9 per cent. The number of police inspectors had 
increased to 124. In introducing the new measure the Chief 
Secretary said the great difficulty was to induce a better 
class of women to register as nurses. He thought that this 
would be overcome by taking the inspection out of the 
hands of the police. In South Australia the Act was 
administered by an honorary council and in New South 
Wales by the chief officer of charitable institutions. Under 
the new Bill the control would be placed in the hands 
of the department for neglected children. That department 
had honorary committees chiefly of ladies throughout 
A'ictoria who were prepared to keep a supervision over the 
children. The payment of lump sums to nurses for taking 
charge of children was to be forbidden absolutely. The 
parents could pay a sum to the department but nurses 
would receive weekly payments. For the first 12 months 
the payment would be 10s. per week. After that the 
rate might be reduced to 7s. per week. There would be 
two or three female inspectors appointed and an extra £1000 
per annum would be required for payments to medical men 
for extra supervision. Particulars of a child’s parentage 
would be kept and revealed only by order of the Minister. 
In certain circumstances a medical certificate of death 
would be accepted instead of the statutory coroner’s inquiry 
as at present. Under the new Bill provision is also made for 
the establishment of maternity homes. 

Public Health in Queensland. 

The annual report of the Commissioner for Public Health, 
Queensland, was presented to Parliament last month and 
covers the work to June 30th. Dr. B. B. Ham refers at some 
length to the inadequacy of means of domestic storage for 
meat and milk and remarks: “The food ‘safe’ and larder 
may often be labelled as infected domestic areas. ” Ophthalmia 
is noted as an increasing danger to children in western 
-Queensland and the need for domestic care and school 
inspection is insisted upon. The inspection of foodstuffs was 
being carried out by the department as, with the exception 
of the Brisbane city council, local authorities continued to 
display great apathy. A marked improvement was generally 
manifested in existing conditions compared with those of a 
few years ago. 

Adelaide Children's Hospital. 

The thirty-first annual meeting of the friends and 
supporters of this institution was held on Oct. 31st under 
the presidency of the Governor of South Australia (Sir G. R. 
Le Hunte). The annual report showed that 593 in-patients 
had been treated with 36 deaths, that 563 surgical opera¬ 
tions bad been performed, and that the out-patient attend¬ 
ances totalled 8161. The revenue of the institution was 
well maintained and the hospital benefits largely from a 
legacy of £200,000 under the will of the late Mr. T. Martin. 
The share of revenue available from this fund will permit 
extension of the hospital buildings in the near future and 
the committee bad already been able to make some additions 
and renewals. The officer-bearers were re-elected on the 
motion of the Bishop of Adelaide. 

Transposition of Viscera. 

A patient recently died in the Queenstown Hospital, 
Tasmania, from acute nephritis. The medical officer noted 
during life that the heart was transposed and a post¬ 
mortem examination revealed complete transposition of all 
the viscera. The deceased was a boiler-maker and had always 
enjoyed vigorous health. 

Nov. 30th, 1907. 


F.R C.P.Lond., F.R.S., 


By the death of Sir Alfred Baring Garrod, which occurred 
on Dec. 28th, 1907, at the advanced age of 88 years, the 
profession of medicine in the United Kingdom loses one of 
its oldest and best known members. 

Alfred Garrod was born in 1819, at Ipswich, and 
received his early education at the Ipswich Grammar School, 
whence, after serving an apprenticeship to Mr. Charles 
Hammond, surgeon to the East Suffolk Hospital, he 
proceeded to University College and the hospital attached 
thereto. He graduated at the University of London, being 
placed first in medicine at the examination for the degree of 
M B. in 1842 and also at that for the degree of 
M.D. in the following year. He became a Member 
of the Royal College of Physicians of London in 
1851, was elected a Fellow in 1856, served as Senior 
Censor in 1887, and as a Vice-President in 1888. In the 
year following his election as Fellew he was the Goulstonian 
lecturer, the subject of his lectures being Diabetes. In 
1858 he received the honour of being made a Fellow of the 
Royal Society of London. In 1883 he delivered the Lumleian 
lectures at the Royal College of Physicians of London, his 
subject being Uric Acid: its Physiology and its Rela¬ 
tion to Renal Calculi and Gravel. As regards his 
career as a practising physician, he was elected assistant 
physician to University College Hospital in 1847 and 
full physician and professor of therapeutics and clinical 
medicine in 1851. In 1863 he became physician to King’s 
College Hospital as well as professor of materia medica 
and therapentics and clinical medicine at the college. 
These posts he held until 1874 when he was made consulting 

Bir Alfred Garrod is best known to the present genera¬ 
tion of medical men by his work upon materia medica, 
originally published in 1855, and by his researches into the 
nature of the pathological conditions which are associated 
with the terms “gout’’and “rheumatics." It was in 1847 
that he discovered the presence of uric acid in the blood 
of gouty patients and a paper by him upon this subject was 
communicated to the Royal Medical and Chirurgical Society 
of London on Feb 8th, 1848, by the late Dr. C. J. B. Williams. 
The paper was received with great interest and Dr. Williams 
pointed out that although he himself had for years taught 
that the presence of lithic acid in the blood was the cause of 
gouty manifestations yet the demonstrative proof that this 
acid did exist in the blood in such circumstances was 
entirely due to Dr. Garrod. The subjects of gout and rheu¬ 
matism continued to interest Dr. Garrod for many years and 
in 1859 he published his well-known work upon the Nature 
and Treatment of Gout and Rheumatic Gout. This latter 
disease he proposed should in future be called rheumatic 
arthritis, a designation which is cow giving way to arthritis 
deformans. It was in this book that he drew attention to 
the use of the lithium salts for gouty conditions. In 1883 
Dr. Garrod delivered the Lumleian lectures as stated above. 
In these lectures he first discussed the probable seat of 
origin in the body of uric acid, alluding naturally to bis own 
discovery of that substance in the blood in 1847. He also 
considered the urines of all classes of the animal kingdom 
with which he bad made many experiments, as he had also 
done with their blood by his now classical thread test. He 
entered very fully into the whole matter, concluding that 
the evidence was strongly in favour of the true renal origin 
of uric acid. He then discussed the bearing of his views on 
calculus formation and the influence of different diets 
upon that disorder, and finally described experiments which 
he had made to check the late Sir (then Dr.) William 
Roberts’s well-known work on the Solubility of Uric Acid 
in Alkaline Carbonates and Other Reagents. This excellent 
course of lectures proclaimed him a patient investigator 
and a clear thinker on a subject in which he was keenly 
interested. In these lectures be did not expound his views 
on uric acid in relation to gout but it is interesting to recall 
them as he expressed them elsewhere. He held that with 
lessened alkalinity of the blood there was increased uric acid 
owing to faulty elimination and that this diminution of 
alkalinity caused the deposition of the sodium urate, which 
required a more alkaline medium to hold it in solution. 

66 Tot Lancet,] 


[Jan. 4, 1908 

The acute paroxysms were due, be considered, to an 
accumulation of uric acid in the circulating blood and their 
sudden crystalline deposition around the affected joint. 
Besides his Lumleian lectures The Lancet at different 
times published interesting communications from Dr. 
Garrod, amongst which we may mention especially a note on 
some chronic diseases of the alimentary canal and liver, 
also of the skin and articulations and their treatment by the 
long-continued use of small doses of sulphur given in the 
form of compound lozenges with cream of tartar, which had 
proved useful in his hands. 1 Another excellent paper con¬ 
tributed to these columns was on Aix-les-Bains and the 
value of its course in rheumatoid arthritis, gout, rheu¬ 
matism, and other diseases. 9 

Although the study of gout and rheumatism ocoupied a 
large portion of his activities he by no means confined 
himself to these subjects. As we have said above, he 
took for the subject of his Goulstonian lectures the condition 
known as diabetes. Materia medica and therapeutics also 
took up much of his attention and his lectures upon the I 
application of the science of chemistry to the dis¬ 
covery, treatment, and cure of disease which were 
delivered at University College Hospital and were pub¬ 
lished in The Lancet of 1848, showed a knowledge of 
the interaction of chemistry, physiology, and pathology which 
in those days was rare. His text-book of “ Materia Medica 
and Therapeutics,” first published in 1855, was the work to 
which medical men and students through the greater part of 
the latter half of the last century were indebted for their 
standard text-book. When Garrod’s book appeared he was 
professor of clinical medicine at University College, his 
chair including the subjects of materia medica and 
therapeutics. The book on its appearance ran to 280 
pages and its value was hardly recognised from the 
first, as nearly ten years had elapsed before a second 
edition was called for, by which time its author had 
changed his allegiance to the King’s College school. 
In 1874 a fourth edition was reached, and of this Dr. 
Buchanan Baxter acted as editor ; the book was by that time 
an established success and 1886 saw the appearance of its 
eleventh edition, for which Dr. Nestor Tirard was responsible 
under the author’s supervision, Bince Dr. Baxter, the first 
editor, bad died. Sir Alfred Garrod was always interested 
in pharmacological and pharmaceutical matters and read 
papers before the medical and other societies on such subjects 
as the action of alkalies on alkaloids. 

He was for some years a Physician Extraordinary 
to the late Queen Victoria who shortly before appointing 
him to this post conferred upon him the honour 
of knighthood at her Jubilee in 1887. On Dec. 6th 
of that same year he received the honour of being 
entertained at a complimentary banquet given by the 
members of his profession resident in bis native town of 
Ipswich. Ilis health was proposed by Dr. W. A. Elliston, 
physician to the East Suffolk and Ipswich Hospital, who, 
our readers will remember, was President of the British 
Medical Association when it met at Ipswich in 1900. Dr. 
Elliston, in referring to Sir Alfred Garrod’s labours on the 
subjects of gout and rheumatic gout, concluded by saying 
that in his opinion the guest of the evening had done for the 
Btudy of these allied diseases what Jenner had done for that 
of continued fever. Our knowledge of these two diseases, or 
should we say our consciousness of what gout and rheu¬ 
matism are not, has grown greatly since the date of the 
appearance of the book in question, but when we reviewed 
the first edition in The Lancet of Dec. 24th, 1859, we 
concluded as follows : We do not hesitate to affirm that we 
never had the pleasure of reviewing a work from the perusal 
of which we have derived more advantage, and we can con¬ 
fidently recommend it as not only highly philosophical but 
likewise thoroughly practical.” 

In his later years Sir Alfred Garrod had wholly 
relinquished practice, and the increasing infirmities of old 
age prevented him from taking any share in the life of the 
profession or appearing in public. He, however, continued 
his experimental work on the subjects in which he was most 
deeply interested. He died quite peacefully from old age 
on Dec. 28oh. 

In 1845 he married Miss Elizabeth Anne Colchester, 
by whom he had six children, of whom three survive 
him. The eldest son, Alfred Henry Garrod, who was a 

1 The Lancet, April 6th, 1889, p. 665. 
9 The Lancet, Mny 4th, 1889, p. 869. 

distinguished biologist and F.R.S., died, aged 33 years, 
in 1879. 

Dr. Nestor Tirard writes to us as follows concerning his 
old teacher:—“ The death of Sir Alfred Baring Garrod at 
an advanced age removes one who in his prime bad an 
enormons influence on the practice of medicine generally and 
on the development of therapeutics in particular. Before 
he became professor of materia medica and therapeutics at 
King’s College he had published a text-book on this subject 
which for very many years was in the hands of most 
students and practitioners. He had also published a treatise 
on gout and rheumatic gout (rheumatoid arthritis), and the 
quotation from J. J. Rousseau on the title-page— 

4 Observez la nature, et auivez la route qu’elle voub trace ’— 

may well be taken as the keynote of his teaching and 
influence upon his students. In his wards and in his lecture 
room he continually referred to clinical observations whether 
relating to the symptoms of disease or to the remedial 
measures to be adopted. This tendency served to vitalise 
the details of materia medica and to encourage others to 
follow in his footsteps. Those who were fortunate enough to 
be bis pupils instinctively felt that he was master of his 
subject and that they had only to name their difficulties to be 
supplied with illuminating explanations and illustrations. 
Some years after the calls of private practice had necessitated 
the relinquishment of his professorial duties and of hospital 
work I again had the advantage of meeting him frequently 
in connexion with the production of a new edition of 
his book on materia medica. In this he took an ex¬ 
tremely active part, personally retaining the control of 
some of the sections, notably that dealing with the different 
mineral waters. When the British Pharmacopoeia of 1898 
was in course of revision Sir Alfred Garrod was chairman of 
the committee appointed by the Royal College of Physicians 
to make suggestions for omissions, additions, and alterations. 
His keen interest led him to preside, if I remember rightly, 
at all the meetings and the changes he advocated invariably 
found ready acceptance. Though he has outlived many 
distinguished pupils and associates, the influence of his 
work is still evident in many directions ; his books may 
still be consulted with advantage and many of us will 
alwavs feel proud of having been privileged to study under 

Sir Dyce Duckworth has kindly sent us the following 
appreciation of the venerable physician's work. “Full of 
years, and regarded with esteem and affectionate regard by 
all who knew him, Sir Alfred Garrod has passed away after 
leaving a record of effective service in his profession which is 
known and appreciated wherever a scientific study of medi¬ 
cine is cultivated. His epooh-making disclosure in 1848 of 
the intimate relation between gouty disturbances and the 
behaviour of uric acid in the system formed a contribution 
of large importance to clinical medicine, one which has 
stimulated research in the same direction, and can 
never be ignored in discussing the still unsolved patho¬ 
logy of gout. All careful observers have had to acknow¬ 
ledge his facts, although different conclusions have 
been drawn from them by various investigators. As an 
exponent of organic and clinical chemistry Garrod’s 
methods were exact and persistent. His laboratory was the 
human organism, ever the best for the bedside physician. 
His discoveries, whether in toxicology, pharmacy, or the 
improvement of the materia medica, were always designed 
in support of the art medcndi, for the benefit of the patient; 
and his success in practice was greatly due to this pro¬ 
cedure, so that it was wont to be said of him that * Garrod’s 
medicines always did good.’ We may cherish this recollec¬ 
tion in these days when some of these matters are greatly 
neglected both in teaching and practice. After all, it was 
Garrod’s method which made him an outstanding man 
amongst his contemporaries, the method of Hunter, to think 
first and then to try, for this gives the best indication in its 
possessor of the mens medica. With this, we, who knew him 
well, recognised his unfailing gentle kindness and sympathy 
and his genial interest in all matters relating to the pro¬ 
fession. When the first Moxon medal was awarded by the 
Royal College of Physicians in 1891 it was felt that no 
worthier British recipient of it could be found than Garrod 
as fulfilling the requirements of ‘ distinguished research and 
observation in clinical medicine.’ Sir Alfred Garrod’s work 
and method have laid a responsibility on all who have entered 
into his labours to follow in the like path of duty and fruitful 
service for our common humanity.” 

The Lancet,] 


[Jan. 4, 1908. 67 

Sir Alfrrd Baring Garrod, M.D. Lond., F.R C.P. Lond., F.R.S. 


(From a photograph taken about 1887.) 

The Lancet ] 


[Jan. 4, 19C8. 

F R.C.S. Edin., Hon. F.R.C.S. Irei,., 


The medical profession in Scotland has lost one of its 
most prominent members by the death of Sir Patrick Heron 
Watson of Edinburgh. The sad event was not unexpectfd, 
for he had been in poor health for some years and during the 
last six months be had been seldom out of doors. Heart 
failure was the cause of death and he passed awav on 
Dec. 21st, 1907, at his residence in Charlotte-square, Edin¬ 

Patrick Heron Watson was a son of the late Rev. 
Charles Watson, D.D., parish minister of Burntisland, Fife- 
shire, and was born on Jan. 5Mi, 1832. In 1853 he graduated 
as M.D. at the University of Edinburgh ; in the same year he 
also became a Licentiate, and two years later a Fellow, of the 
Royal College of Surgeons of Edinburgh. On the outbreak 
of the Crimean war he joined the Army Medical Corps as 
staff assistant surgeon, afterwards being assistant surgeon in 
the Artillery and Royal Horse Artillery For six weeks after 
reaching the Crimea he was invalided with typhus fever and 
then was attached to the battery at Bilaclava, where he had 
dysentery and was seriously ill. For his services in the war 
he received the Crimean, Turkish, and Sardinian medals 
On his return home Dr. Watson commenced the teaching 
of surgery at High School Yards, Edinburgh ; was subse¬ 
quently elected lecturer on systematic and clinical sur¬ 
gery at the school of the Royal College of Surgeons of 
Edinburgh ; and was then appointed surgeon to the Royal 
Infirmary, of which he continued a consulting surgeon. 
He was also consultirg surgeon to Leith Hospital and 
surgeon at Chalmers Hospital, Edinburgh. He represented 
the Royal College of Surgeons of Edinburgh on the General 
Medical Council from 1882 to 1906, succeeding the late 
Mr. James Spence and being himself succeeded by Dr. 
J. W. B. Hodsdon. He was also a member of the Edin¬ 
burgh University Court, a curator of patronage, and an 
honorary Fellow of the Royal College of Surgeons in Ireland. 
In 1884 he received the distinction of LL.D. from the 
University of Edinburgh; he was an honorary surgeon in 
Scotland to Queen Victoria and was honorary surgeon 
to the King. He was a Chevalier of the Order of Carlos III. 
of Spain, was a surgeon of the 5fch Volunteer Infantry 
Brigade, and held the Volunteer Decoration. He was 
also a Deputy Lieutenant of the City of Edinburgh. 
No surgeon was more widely known in Scotland, and 
his services as operator or consultng surgeon were in 
request in difficult cases all over the country. In July, 
1903. he received the honour of knighthood. As President of 
the Royal College of Surgeons of Edinburgh he took a lead¬ 
ing part in the celebrations of the quatercenterary of the 
College in 1905. That was the second occasion upon which 
he bad held t.he position of President, the previous occasion 
being in 1878. His principal published works, with their 
dates, were “The Modern Pathology and Treatment of 
Venereal Disease” (1861) and “Excision of the Knee- 
joint” (1867) He also edited the late Professor James 
Miller’s “System of Surgery.” He married a daughter of 
Professor Miller to whom he acted as assistant for several 
years after his return from the Crimea. His wife pre¬ 
deceased him several years ago but he is survived by two 
daughters and two sons. 

For the following appreciation of the life and work of the 
deceased we are indebted to Mr. Rutherford Morison of 

“The death of Sir Patrick Heron Watson must leave in the 
minds of his old pupils a sense of painful bereavement, for 
his was a unique and impressive personality. To his old 
bouse surgeons he was a hero they worshipped, for to work 
with him was an inspiration which could not fail to leave it6 
mark on the least plastic of men. It was my privilege to act 
as his resident surgeon in the year 1875 in the old Royal 
Infirmary at Edinburgh. His reputation was then made and 
he was universally recognised as one of the foremost 
operators in the world. He had already performed most of 
the abdominal operations which are now common property, 
and had excised the spleen, the kidney, ovarian and uterine 
tumours, and portions of intestine at a time when it was 
thought impossible to bring such undertakings to a success¬ 
ful issue. He had then also excised the whole larynx for 
malignant disease and had performed Feveral successful 
thyroidectomies by a new and original method, since 
generally adopted, of ligaturing the arteries of supply before 

interfering with the gland itself. It has indeed often seemed* 
to me, in looking back to the time when I was working with 
him, that most of what he did then is the operative surgery of 
to-day and was at least 20 years in advance of that period. 
That he has not received the recognition as a surgical pioneer 
he deserved is due solely to the fact that he failed to avail* 
himself, as so many of the strongest and ablest men of that 
generation did, of the revolution in the treatment of wounds 
which was being brought about by Lord Lister. It was 
impossible for him to accept the new principles in the whole¬ 
hearted fashion necessary to carrying out the details with 
success. Operations such as lateral lithotomy, excision of 
the jaw and tongue and rectum, which he performed with a 
skill I Dever saw equalled, gave brilliant results ; many 
others, more dependent on attention to antiseptic detail, were 
in spite of his diagnostic ability and manipulative dexterity 
doomed to failure. 

At the time previously mentioned (1875) and for twenty 
years afterwards his whole time was busily occupied by pro¬ 
fessional work. In addition to the largest surgical practice 
in Scotland, consulting and operating, he constantly had 
medical patients with all sorts of ailments under his care, 
and how he managed to get through all he had to do was a 
mystery to his friends. Yet he never appeared to be in a 
hurry and always found time to spare for his hospital work 
and surgical lectures and private pathological museum. 
Patients came from all parts of the world to consult 
him and with such faith it was a common saying in 
Edinburgh 4 that most of them would rather be killed 
by Dr. Watson than cured by anyone else.’ Small wonder 
that patients trusted him. Everyone who saw him felt at 
once his strength and capacity. Every surgeon must have 
experienced after finishing an anxious and difficult operation 
doubt as to whether he did the best that could be done to 
meet some sudden and unforeKpen emergency, but nobody 
ever doubted this of Sir Patrick Heron Watson. He seemed 
to have considered every possibility beforehand, and any 
difficulties were so quietly met and so methodically dealt 
with that they could not appear, except to the initiated, as 
difficulties at all. There was a stronger individuality about 
Dr. Watson than about anyone else I have known and though 
this cannot be conveyed to strangers his old house surgeons 
will remember his military walk, his correct attire, his 
neat, plainly-written notes, his method of interviewing and 
prescribing for out-patients, his courteous manners, his 
independence of character, and his ready command of 
language, which might not always be to their satisfaction 
hut was always to their lasting advantage, as peculiarly hia 
own. There are many of us who will revere these memories 
for we loved the man.” _ 

M.R.C.S. Eng., L.S.A. 

The medical profession in Wrexham and district has lost 
one of its kindest and most lo*val colleagues in the lamented 
death of Dr. J. Llewelyn Williams of Holt street House, 
which occurred somewhat suddenly on Friday evening, 
Dec. 13th, 1907, from heart disease. By his death the profes¬ 
sion suffers a severe loss and to those who knew him best his 
sterling qualities and steadfast friendship will ever remain as 
cherished memories. Dr. Williams was the son of the late 
Dr. Edward Williams, who died in 1893. after many years 
of extensive practice in Wrexham and the surrounding 
neighbourhood. Dr Llewelyn Williams, like his father, 
was an ideal “family doctor.” His gentle voice, honest, 
grave eyes, and sympathetic personality did much ta 
cheer and help those in suffering and sorrow; always 
patient and ready to hear and to sympathise with their minor 
troubles and worries, he Dever left a bedside without a cheery 
word of help and comfoit for his patient. Dr. Williams 
to< k his medical course at the University of Edinburgh, 
where he graduated with the degrees of Bachelor of Medicine 
and Master of 8urgery in 1867 ; he al>o studied at St. Bartho¬ 
lomew’s Hospital and qualified as M.R C S. Eng. and L S. A. 
He was a justice of the peace for the county of Denbigh¬ 
shire and took a keen interest in his magisterial work. 

In 1876 he was elected honorary surgeon to the Wrexham 
Infirmary, a post which he held until 1881. During this 
period he gave his time, experience, skill, and encourage¬ 
ment to the suffering poor under his care, and there the 
kindly acts and unostentatious aid rerdered to so many in 
a humbler sphere, although unrecorded, will not be forgotten. 
When a vacancy occurred later on the staff of that institution 

70 Thjc Lancet,] 


[Jan. 4,1908. 

he was urged by some of his colleagues to apply for that 
post but could not be induced to do so. He was for some 
years medical officer of health of the borough of Wrexham 
and rendered valuable services in the advancement of sanitary 
science and public health. He was a former president of the 
North Wales branch of the British Medical Association and 
his year of office was a most successful one. He had high 
ideals of medical ethics and his advice was always in con¬ 
sonance with the best traditions of the duties of members of 
the profession to the public and to one another. Not the 
least of his characteristics were bis modesty and unassuming 
manner. To all who knew him he was the embodiment of 
uprightness of conduct and he lived and died a pattern cot 
only of a good physician but of an English gentleman. 

and Edin., D.C.L. Durh., 


It is difficult for those who knew Professor Annandale 
and frequently saw him going to, or returning from, the 
infirmary to realise that his figure has finally disappeared 
from the streets of Edinburgh. l*'ew men were more widely 
known to sight by the general public. No one would have 
guessed that he would so suddenly have been removed from 
the sphere of active surgical work. On Thursday afternoon, 
Dec. 19th, 1907, he operated in the infirmary, dined at home, 
retired early as was his habit, and on Friday morning was 
found dead in bed. That this was a great shock to his 
colleagues and professional friends can easily be realised. 
There had been no bint of indisposition of any kind ; no man 
seemed to carry his years more easily ; no man appeared 
more equable or seemed to work with greater ease; and 
yet within the space of a few hours he passes from 
the operating theatre to the final bourne. That bis more 
intimate friends in the Senatus and outside should have 
been stunned by the occurrence is not difficult to realise. 

Professor Annandale was born in November. 1838, so 
that he had only reached his sixty-ninth year. He 
was a native of Newcastle and made his first acquaintance 
with surgery in the hospital of that town and in his father’s 
practice. In 1856 he became a student of medicine in Edin¬ 
burgh. He graduated in 1860 and received a gold medal for 
bis thesis on the Injuries and Diseases of the Hip-joint. In 
1859 he obtained the M.R.C.8. Eng. Immediately after 
graduation he became house surgeon to Professor Syme, 
a post which he held for 12 months. In this position he so 
impressed his great master with his surgical capacity that 
Syme made him his private assistant. He occupied this 
important position from 1861 to 1870, when Syme died. He 
accompanied his master to operations all over the country 
and when he became a candidate for an honorary surgeoncy 
in the infirmary he had Professor Syme's warm support, a 
support which no doubt weighed heavily in determining 
his appointment. Before this appointment he had been 
awarded the Jacksonian prize for his essay on the 
Malformations, Diseases, and Injuries of the Fingers and 
Toes and their Surgical Treatment. In 1871 he became a 
full surgeon to the infirmary and became entitled to 
lecture on olinical surgery. He was a popular lecturer and 
always drew a large number of students to his lectures and 
his ward clinics. When in 1877 Professor (now Lord) Lister 
resigned the chair of clinical surgery Mr. Annandale was 
appointed his successor. This post he filled until his death. 
Professor Annandale’s professional life was thus spread over 
a very remarkable period in the history of surgery. He 
began surgery at a time when expertness and dexterity, 
nerve, and courage were absolutely necessary to the surgeon. 
He had as his master in these departments the great Syme. 
Meanwhile Lister was slowly, laboriously, but surely laying 
the foundations of a scientific side of surgery that was 
destined to revolutionise the whole practice and to transfer 
technical dexterity with the operating knife to dexterity in 
asepsis. Following upon this came abdominal surgery where 
patient labour in the depths of that cavity led to the great 
victories gained in this region. Professor Annandale’s 45 
years of active surgical work thus covered a time marked 
by the beginning, the growth, and the complete success of 
a revolution in his own department. 

In virtue of his surgical instinct and his great experience 
bis opinion was often invaluable ; his dexterity, resourceful¬ 
ness, and nerve never forsook him. He was known wherever 
Edinburgh graduates were placed ; he was proud of his 
friends and former students dotted all over the globe ; he 

used to boast that he had operated in three, if not in four, 
continents. He was a member of various learned societies 
and he was Burgeon-General to H.M. the King’s Bodyguard 
for Scotland—the Royal Archers. In all University matters 
he took the warmest interest, especially in all matters 
affecting the comfort, or well-being, or interests of the 
students. He took a prominent part in connexion with the 
Students’ Union and with the Athletic Club and otherprojects 
which he regarded as for the good of the students. He was 
much liked by them; indeed, their liking amounted to 
affection. He was a kind-hearted, friendly, and genial 
influence in Edinburgh medical life. 

Professor Annandale married in 1874 a daughter of the late 
Mr. William Nelson, of the well-known publishing firm. 
There was a family of three sons and three daughters. The 
funeral took place on Dec. 23rd from St. John's Episcopal 
Church to the Dean Cemetery. 

Dkaths op Eminent Foreign Medical Men. —The 
deaths of the following eminent foreign medical men are 
announced:—Professor Adalbert Tobold, privat-doeent of 
laryngology and rhinoscopy in the University of Berlin. 
Dr. Oskar Lassar, primt-docent of dermatology and syphilis 
in the University of Berlin. 

SUttral jUtos. 

University of Cambridge.— The following 

appointments have been made: Senior Demonstrator in 
Anatomy, Dr. W. L. H. Duckworth; Junior Demonstrator in 
Anatomy, Dr. D. G. Reid. The following has been exa¬ 
mined and approved for the degree of Master of Surgery:— 
E. W. Sheaf, Donning. 

At examinations for Medical and Surgical Degrees held in 
Michaelmas Term, 1907, the following candidates were 
successful :— 

Second M.B. Examination. 

Unman Anatomy and Physiology.— R. L. Barker, B.A., Caius ; F. S. 
Bedale Clare; J. P. Benskin, Christ's; D. C. Bluett, Emmanuel; 
C. H. B. Booth, King's; E. G. S. Cane, B.A., Jesus; R. G. Canti, 
B.A., King’s; R. F. P. Cory, B.A., C&ius; II. T. Depree, B.A., 
Clare; C. Ede, King’s; K. Ellis, B.A., Catharine; A. G. Evans, 
Trinitv; J. T. Fox, B.A., Sidnev Sussex; A. W. Gaye, B.A., Caius; 
A. C. Uemmell, B.A., Trinity ; R. W. B. Gibson, B.A., Jesus; H.K. 
Griffith, B.A., Trinity; L. S. M. Habich, B.A., St. John’B; J. B. 
]Is nee, Christ’s; L. C. D. Irvine, Emmanuel; A. C. Jepson, B.A., 
Pembroke; J. C. John, King’s; L. F. G. Lewis, B.A., Christ’s; 
J. R. Marrack, St. John's; W. G. Marsden, Emmanuel; C. C. 
Mess iter, B.A.. C. G. H. Moore, B.A., and P. A. Ople. B.A , Caius; 

G. M. Parker, B.A.. Emmanuel; A. B. Pavey-Smith, Clare; J. W. 
Pigeon, Christ’s ; H. B. Pope, Caius; F. A. Powell, B.A., Trinity; 
R. A. Ramsay, Caius; K. Rayner, Pembroke; W. D. Ross King’s; 

A. Sandlson, B.A., Trinity; F. P. Saunders, B.A.. Clare; W. 
Shipton, B.A., Emmanuel; I. Singh, B.A., Pembroke; G. N. 
Slathers, Trinity; F. J. Thorne, B.A..Jesus; P. B. Wallis, B.A., 
Pembroke ; and F. H. Watson, B.A., and J. B. A. Wigmore, Caius. 

Third M.B. Examination. 

Part II. , Surgery, Midwifery, and Medicine.— J. B. Banister, M.A., 
Jesus; J. W. B. Bean. B.A., 11. Selwyn; E. Beaton, B.A., Caius; 

H. S. Berry, M.A., Clare: C. W. Bowie, B.A., Trinity; D. W. A. 
Bull, B.A., Caius; B. P. Campbell, B.A., Clare; J. It. C. Canney, 

B. A., Christ’s; H. B. Carlyll, B.A., St.John's; R. G. Chase, B.A., 
Trinity; R. N. Chopra, B.A., Downing; F. Clayton, B.A., Trinity; 
H. N. Coleman, B.A., Christ’s ; G. H. Davy, B.A., Caius; A. W. C. 
Drake, B.A , Pembroke; N. M. Fergusson, B.A.. Magdalene; G. B. 
Fleming. B.A.. King's; R. L. Gamlen, B.A., Caius; G. Graham, 
B.A.. Trinity; F. W. W. Griffin, B.A., Kings; O. Heath, B.A., 
Trinity; E. B. Hinde, B.A., Emmanuel; A. F. Jackson, B.A., 
Peterhouse; K. A. Lees, B.A., King’s; S. G. Luker, M.A., 
Pembroke; M. W. B. Oliver, B.A., Trinity; E. V. Oulton, B.A., 
Christ's; B. II. Palmer, B.A., Pembroke; W. G. Parkinson, B.A., 
Emmanuel; B. A. I. Peters, B.A., Jcsub; J. II. Ryffel, M.A., 
Peterhouse; L. Shingleton-Smith, B.A., St. John’s; E. Slack, 
M.A., Pembroke; E. C. Sparrow, B.A., Trinity; H. H. Taylor, 
B.A., Pembroke; C. H. Treadgold, M A., Clare; F. B. Treves, 
B.A., Caius; P. J. Verrall, B.A.. Trinity; K. M. Walker, B.A., 
Caius; and A. Wilkin, B.A., King's. 

London School of Tropical Medicine.—T he 
following students of the above school successfully passed 
the examination in Tropical Medicine held at the end of the 
twenty-fifth session,October to December, 1907 :— 

•Graham U. Smith, M IL, D.P.II., M.R.C.S., L.R.C.P.; "Major W. 
Westropp White, I.M.S., M.D.. M.Ch., M.A.O.; *H. L. Deck, 
M.R.C S., L.K C.P.; *J. Cross, M.B., Ch.B.; G. II. Hustler, M.B., 
Ch.B. (Colonial Service); Captain M. J. Quirke, I.MS., M.B., 
Ch.B.; F. L. Henderson, M.K C.S., L.R.C.P. (Colonial Service); 
T. L. Craig, M B., B.Ch. (Colonial Service); W. R. Larbalestier, 

L. R.C.P., M. H.C.S., L.D.S. (Colonial Service); A. E. Oakeley. 

M. R.C.S., L.R.C.P.; W. R. Gibson, F.K.C.S., L.R.C.P.; F. A. 

The Lancet,] 


[Jan. 4,1908 . 71 

Wille. M B., Ch.B., AI D , D.P.1I. ; T. 

M.R.C.V.S. ; K. Fltzllerbert Johnson, 

Snell. L.K.C.P., L.R.C.S. (Colonial Servi 
# With distinction. 

Donations and Bequests.— Under the will of 

Mr. Isaac Coley of Peckbam, S.E., Gay’s Hospital, St. 
Thomas’s Hospital, University College Hospital, and the 
Lying-in-Hospital will each benefit by a sum of about £3000. 

Medical Magistrates.— The Lord Chancellor 

has, on the recommendation of the Dnke of Fife, the Lord 
Lieutenant of the county, added the name of Dr. R. J. Collie 
to the commission of the peace for the county of London.— 
Dr. Henry Willson of Weybridge has been placed upon the 
commission of the peace for the county of Surrey. 

Presentation to a Medical Practitioner.— 

Mr. J. W. Smith, M.R.O.S. Eng., L.S.A., was on Dec. 25th 
last presented with a motor-car with accessories and 
motor-house by the inhabitants of Weaverham, Acton, 
Delamere, Cuddington, Norley, and surrounding districts in 
recognition of 40 years’ professional servioes and 18 years’ 
service as a Cheshire county councillor. 

Tragic Death of a Medical Man.—D r. George 

John Sealy of Weybridge, Surrey, lost his life on Dec. 24th 
last in a tragic manner. He was riding on horseback witb his 
groom along the towpath towards Chertsey. Owing to the 
floods the path was quite unsafe and near Chertsey Bridge 
Dr. Sealy’s horse, which was leading, plunged and slipped, 
with the result that both horse and rider were precipitated 
into the river. The horse managed to get out again but 
nothing could be seen of Dr. Sealy. The groom dismounted 
and tried to render assistance, as did also the driver of a van 
who witnessed the accident but neither could render any 
help to rescue the unfortunate medical man. Dr. Sealy 
became M.R.C.S. Eng. and L.S.A. in 1861 and M.D. 
St. Andrews in 18b2 and worked in conjunction with Dr. 
K. D. R. Crofton-Atkins of Weybridge. 

The Children’s Sanatorium (Holt, Norfolk). 
—A first report, with accounts from March, 1904, to 
Dec. 31st, 1906. with a list of subscribers, has recently been 
issued. The sanatorium is established for the treatment of 
children, few Banatoriums taking children under the age of 16 
years. The age of admission for girls is from two to 16 years 
and for boys (until permanent buildings are erected) from two 
to seven years. Cases must be in the early stage of pulmonary 
tuberculosis. Payment for cases depends ou the condition 
of the maintenance fund. A limited number of cases are 
received at 7». 6 d. per week, other cases at 15*. per week, 
and other cases from unions or other local authorities are 
received by special arrangement. The length of stay 
depends upon the report of the visiting medical officer 
(Dr. J. B. Gillam of Holt) and upon the continuance of the 
payment, if any. On August 1st, 1906, the first batch 
of children arrived at Holt, “and up to the present 
time” (presumably the end of October, 1907) some 
21 cases have been received. From the accounts we 
gather that £220 have been spent on the maintenance 
of cases, and that of the 21 cases so far taken 15 
have paid 7*. 6 d. a week, five have paid 15*. a week, and 
one has been taken free. The income annually required to 
maintain always 15 cases (a full occupation of the accommo¬ 
dation), if taken quite free, would amount to £850, or if the 
same number of children were to pay 7*. 6 d. per week each 
the sum necessary would be £550 per annum. The com¬ 
mittee, however, appeals for an annual subscription of £700 
in order that about half the cases may be taken without 
payment and half at 7*. 6 d. per week. It also appeals 
for donations to the buildiDg fund. Dr. F. W. Burton- 
Fanning of Norwich, who is the honorary consulting 
physician, states that the Children's Sanatorium has 
acquired an ideal site at Holt and he trusts that it 
will be supported in its endeavours to supply a pressing 
want. Donations for the building fund, or donations or 
annual subscriptions for the maintenance of cases fund will 
be gratefully received by the honorary secretary of the sana¬ 
torium (Mr. T. H. Wyatt, M.V.O.), at 68. Denison House, 

A anxhall Bridge-road, London, S.W. The bankers are 
Messrs. Hoareand Co., London. The Rev. E. C. Bedford is 
the chairman of the committee and the treasurer is Mr. Alfred 
Hoare. As soon as the money is forthcoming 50 patients can 
be dealt with. Holt (near Cromer) should be ot interest to 
Cambridge graduates on account of its connexion with Sir 

Thomas Gresham, “ the Royal Merchant,” who went to Cains 
College, Cambridge, and who, it is recorded, was called by 
Caios “ Doctissimus mercator.” Some authorities say he 
was born at Holt, but more maintain that London was his 
birthplace. However, he founded a school at Holt. 

Derbyshire Women’s Hospital.— The new 

buildings which form the extension of the Derbyshire 
Women’s Hospital, Derby, were opened on Dec. 12th, 1907, by 
Lady Fitzherbert. The new buildings comprise an out-patient 
department, with waiting-room for 50 people, consulting and 
retiring rooms, and a dispensary ; a ward containing seven 
beds and two smaller wards for such cases as are being 
treated apart ; additional accommodation for the nursing 
and domestic staff; and a laboratory and workroom. The 
estimated cost of the additions to the hospital is about £2000. 
The hospital was founded in 1891, during which year 34 
patients were treated. In 19C6 the in patients numbered 136 
and the out-patients 1284. 

Livingstone College.— Satisfactory progress 

in the work of this college is shown by the report for the 
year 1906-07, which was adopted at the annual general 
meeting of members held at the college, Leyton, London, 
E., on Dec. 10th, 1907. The deficiency of £522 at 
the commencement of the financial year has been re¬ 
duced to one of £404. 32 students entered for the 

whole or part of the complete session of nine months, 
representing 15 different missionary societies, some of 
these coming from Germany, Switzerland, Sweden, 
Finland, and South Africa. The report points out that 
missionaries abroad are often responsible for the education 
of the young in the districts in which they are placed, 
and that they may be the means of giving instruction in 
hygiene, which may be of the utmost importance to the 
people of the country. Malaria, plague, and sleeping sick¬ 
ness are all of them, to a considerable extent, preventable 
diseases, and Livingstone College students may do much to 
combat their ravages. 

Leprosy in India.— At Sabathu, where there 

is a large leper asylum for natives, a small cottage 
was set apart some time ago by Dr. Carleton, tbe 
American missionary in charge, for two European young 
women who had contracted the disease, and recently the 
number of inmates has been increased to five by the admis* 
sion of two boys and a middle-aged man, all three with white 
skins. The price of grain food in India is at present very high, 
and we learn from the Timet of India that mainly owing to 
this cause the bank account of the Mission to Lepers, of 
which Mr. Wellesley O. Bailey is superintendent, is now over¬ 
drawn to the extent of £1000. In Purulia, where there are 700 
lepers in the asylum, the food is being bought at what once 
were considered famine rates, and at the Allahabad asylum 
the ‘difference between former and present cost comes to 
Rs. 150 a month. Similarly depressing accounts are fur¬ 
nished by the numerous asylums in other parts of India 
which are dependent on the Mission. It is proposed to hold 
a conference next February at Purulia and delegates from 
Bengal, the United Provinces, the Central Provinces, and 
Central India are expected to attend. 

The Weymouth and District Medical Club.— 
This club has recently been started on what is believed to be 
original lines. All resident medical men, active or retired, 
are eligible for membership, whilst Service men are invited 
to attend, as honorary members, the ordinary meetings of the 
club. The objects of the club are stated in its rules to be 
“the promotion of social intercourse and mutual support in 
any difficulties which may arise from time to time affecting 
the profession or individual members.’’ The former object 
is attained by engaging a room in a central hotel, the 
Gloucester, in which the members may meet without any 
formality on ODe evening of each month in the winter, whilst 
provision is made for the latter by putting it into tbe power 
of any two members to bring any matter to the consideration 
of an early meeting of the committee, which consists of all 
the resident medical men in active practice. No permanent 
chairman or president is appointed but a new departure is 
made by a rule which places in the chair at any meeting 
of the club that member present who has been longest in 
actual practice in the district. An inauguration dinner, 
which was held at the Gloucester Hotel on Dec. 17th, 
1907, was a great success and was attended by nearly 
every medical man in the place, the navy being well 
represented. The rule placing in tbe chair the senior 

F. Macdonald, M.B., C.M., 
M.B., Ch.B. i and W. S. 

72 The Lancet,] 


[Jan. 4, 1908. 

practitioner present worked appropriately by making 
■President for the evening Dr. R. Palgrave Simpson who, 
after 40 years’ practice in Weymouth, is shortly retiring. 
An excellent dinner was served and after the toast of “The 
King ” allusion was made to the approaching departure of 
Dr. Simpson and his health was enthusiastically drunk. In 
returning thanks the chairman recalled the fact that he was 
the sole surviving representative of the old local book club 
which was already defunct before the arrival in Weymouth 
of any other medical man present. The remainder of the 
evening was occupied by an excellent programme of music 
and at the close of a very pleasant gathering the club con¬ 
gratulated itself on a most propitious “ send-off." 

Royal Microscopical Society.— At the Royal 
Microscopical Society on Dec. 18th, 1907, Mr. J. E Bernard 
showed a number of luminous bacterial cultures in test- 
tubes and flasks. He said that the bacteria were all of 
marine origin and that they were cultivated in an ordinary 
gelatine medium to which certain salts had been added. At 
first he used the chlorides of sodium, potassium, and 
magnesium in proportions resembling those in which they 
occurred in sea water, but he afterwards found that quite 
different salts, such as phosphate of sodium, were equally 
suitable provided the solution was isotonic to sea water. 
The light emitted was very nearly monochromatic, 
being included almost entirely between the F and 
•G lines of the solar spectrum. The curve of light 
energy therefore rose and fell very abruptly, forming 
quite a contrast to the gradual rise and fall of the similar 
curve for sunlight. Before leaving this subject we may 
mention that directions for the cultivation of tbe*e organisms 
will be found in The Lancet of Oct 13th, 1900, p. 1087. 
A paper by Mr. E. M Nelson on Gregory and Wright’s 
Microscope was read by the secretary. This microscope was 
made about 1786 by the firm of Gregory and Wright who 
were probably the successors of Benjamin Martin. It was a 
stage focusser and was described as an “ aquatic microscope ” 
—i.e., one in which the object-glass moved over the object 
instead of the object moviDg under the object-glass. Some of 
•the features of Ooerl si user's drum microscope, made in 1835, 
Were described. Another paper by Mr. Nelson, also read by the 
secretary and entitled “A Correction for a Spectroscope," 
suggested that the telescope of a spectroscope should have 
its object-glass pivoted so that the rays emerging from the 
prism might be received by it at varying angles. The 
secretary also read a paper entitled “ Some African Rotifers," 
by Mr. James Murray who was at preEent on his way to the 
Antarctic regions. Mr. Eustace Large exhibited as polari- 
scope objects a variety of sections of selenite illustrating the 
phenomena of “twinning.” They were shown both in table 
polariscopes and under low powers of the microscope ; the 
visible effects consisted of brilliantly coloured geometric 
patterns. _ 


-Perla do. Paez y ca (Sociedad en Oomandita) (Sucesores de 
Hernando). Arena]. 11, 7 Quintana, 31. Madrid. 

Diagnostico y Tratamiento de las Knfermeriades de Irs Vi as 
UrinarUs. Lecciones elementales. Por Alberto Suarez de 
Mendoza, Profesor de Enfermedades de las Vlas Uriuari&s en 
la Facultad de Medicinade Madrid. Price 15 pesetas. 

Richards. Grant, 7.Carlton-street. London, S W. 

The Birds of the British Islands By Charles Stonbam, C.M.G. 
F.R.C 3., F.Z.S With illustrations by Lilian M. Me.iland. In 
20 parts. Part VIII. Price Is. 6d net. 

Rueff, J., 6 and 8, Rue da Louvre, Paris. (En Vente chez Vigot 
FRkRES, Paris.) 

Les Ferments Metalliques et leur Ktnploi en Th^rapeutique. Par 
Albert Kobin, Profe&seur de Clinique Therapeutique a la Faculie, 
Membre de l’Acadgmie de Medeciue. Frlce Fr 4. 

-Schoetz. Richard, Wilhelmstr&sse, 10. Berlin. 

Der tatsitchliche Krebserreger. sein Zyklus und seine Dauersporei. 
Von Dr. Robert Behla, Goheimor Medizinairat. Price M. 4.50. 

Walkfr, John, and Co., Limited, FarriDgdon House, Warwick lane, 
Loudon, E.C. 

Walker's Diaries for 1908. No. 7/77, American Russia, 3«. No. 23- 
Long-Grain, 2s. 6d. 17/417. Graphic, a* did Basil Is 6 d. 4/64, 
Long-Grain, 2s. 6 d. 3/53. cloth, 9d. 2/62, Long-Grain, Is. 6d- 
1/111, Solid Basil, Is. 1/81, Solid Pigskin, Is. 6 d. Quarterly 
Diary (Vest Pocket), Long-Gram, Is. 

Whitaker, J., and Sons, Limited, 12, Warwick-lane, Paternoster-row, 
London, E.C. 

An Almanack for the Year of our Lord 1908. By Joseph Whitaker, 
F.S.A. (Whitaker's Almanack). Price 2s. 6d. net. 

Whitaker s Peerage, Baronetage, Knightage, and Companionage for 
the Year 1908. Price 2s. 6d. net. 

Wilson. Effingham, 54, Threadneedle street, London, E C. 

A Practical Guide to the Dealh Duties and to tbe Preparation of 
Death tmty Accounts. By Charles Beatty, S--lieifcor, if the 
Estate Duty Office. Somerset House. Second edition (Revised 
arid enlarged). Price 4s. 

Wright and Potter Printing Company, State Printers, 18, Post 
Office-square, Boston. 

Twenty-eighth Annual Report of the State Board of Health of 
Massachusetts. Price not stated. 


Successful applicants for Vacancies, Secretaries of Public Institutions, 
ana others possessing information suitable for this column, are 
iynnted to forward to Thk Lancet Office, directed to the Sub- 
Editor, not later than 9 o'clock on the Thursday morning of each 
week, such information for gratuitous publication. 

Attenborough, Wilfrid, M.R.C.S., L.R C.P. Lond , has been 
appointed House Physician at Addenbrooke's Hospital, Cambridge. 

Byrnk, P. Kevin, M.D., M.K C.P. Loud., has been appointed Assistant 
Physician to the London Temperance Hospital. 

Clark, Robert V., M.B. Edin., has been appointed Medical Officer of 
Health of Leeds. 

Corbin. H. K.. M.K.C.S., L.R.C.P. Lond., D.P.H., has been appointed 
Medical Officer of Health of Stockport. 

Dimock. Horace, M.B., B C. Cantab., has been appointed House Sur¬ 
geon at Addeubrooke’s Hospital, Cambridge. 

Hailstone, J. E., M.R.C.S., L.K.C.P. Lond., has been Appointed 
Assistant House Surgeon at Addenbrooke's Hospital, Cambridge. 

Hawes, Ivon Henry Skipwith, M.B., B.S. Durh., has been appointed 
Medical Officer for the Wick District by the Chipping Sodbury 
(Glouc6Btersbire> Board of Guardians. 

Higgs, F. W.. M.B, B.S. Lond., M.R.C.P. Lond., has been appointed 
Medical Registrar to St. George's Hospital. 

HosfoRD, J. Stroud, F.R.C.S. Edin., has been appointed Assistant 
Ophthalmic Surgeon to tbe London Temperance Hospital. 

Houhigan, VV. P., L.U.C.S. Irel., L.R.C.P. Edin.. has been appointed 
Certifying Surgeou under the Factory and Workshop Act for the 
Freshford District of the county of Kilkenny. 

Hunter, William. M.D.. C.M. Edin., FR C.P. Lond., has been 
appointed Physician to Charing Cross Hospital. 

Jameson, K. C.. M.B., C.M. Kdiu., has been appointed Honorary 
Clinical Assistant to the Eye and Ear Department of the Leeds 
Public Dispensary. 

Johnsjn, L. Capper, M.B. Lond.. Ch.B. Vlct., M.R.C.8., L R.C.P. 
Lond., has been re-appointed Honorary Amesthetist to the Sur¬ 
gical Department of the Leeds Public Dispensary. 

Leggf.. J. H, M.B., B Sc. Lond., has been appointed Honorary 
Amesthetist to the Dental Department of the Leeds Public 

MacIIalr, P. J., L.R.C.P. & S. Irel., has been appointed Certifying 
Surgeon under the Factory and Workshop Act for the Belmullet 
District of the county of Mayo. 

Maclure, W. J ., M.B., B.S. Glasg., has been appointed Certifying 
Surgeou under the Factory and Workshop Act lor the Conis- 
borougb District.»f tbe county of York. 

O’Gkvdy. F. If. L.R.C.S. Irel., L.K.Q.C.P. Irel., has been appointed 
Certifying Surgeon under the Factory and Workshop Act for the 
Swineford District of the county of Mayo. 

Quick Hamilton Ernest, B.Sc., M.B., B.S. Lond., L.U.C.P., 
M.R.C.S., has been appointed House Surgeon at the Swansea 

Sandilands. J. K., M.D. Cantab.. M.R.C.S., has been appointed Certify¬ 
ing Surgeon under the Factory and Workshop Act for the 
Winchester District of the county of Hants. 

Spriggs. N. I.. M.K.C.S., L.K.C.P. Lond.. has been appointed Certify- 
ing Surgeon uuder the Factory and Workshop Act for the 
Shrewsbury Disirict of the county of Salop. 

Sutcliffe, Amelia, M.B., Cb.B.Edin., has been reappointed 
Honorary Clinical Assistant to the Leeds Public Dispensary. 

Thomson, May. L.ll.C.P. A S. Edin.. L.F.P.3. Glasg., L.M. Dub., 
has been re-app.duted Honorary Clinical Assistant to the Leeds 
Public Dispensary. 

Ward, J., M.K.C.S.. L.S.A.^has been appointed Certifying Surgeon 
under tbe Factory and Worksh »p Act for the Leainlugton District 
oi tbe county of Warwick. 

Whalley, Frederick, M.B., Ch.B. Leeds, has been appointed Hono¬ 
rary Anesthetist to the Dental Department of the Leeds Public 

Whitehead, Francis Henry, L.R.C.P. Lond., M.R.C.S., has been 
appointed Medical Officer to t he Post Office at Battersea, 3. W. 

Wilson. E. Ai-lan, M.D. Lond., M.R.C.S., L.K.C.P. Lond., has 
been re appointed Honorary Anaesthetist to the Dental Depart¬ 
ment of the Leeds Public Dispensary. 


For f urther information regarding each vacancy reference should be 
made to the advertisement (see Index). 

Bootlk Hospital for Infectious Diseases.— Resident Medical 
Officer unmarried. Salary £100 per annum, with board, washing, 
and apartments. 

Brighton, Susan x County Hospital. —Third House Surgeon, un¬ 
married. Salary £50 per annum, with board, residence, aud 
wash fug. 

Burslkm, Borough of.— Medical Inspector of Children in Public 
Elementary Schools (female). Salary at rate of £150 per annum, 
rising to £200. 

Thb Lancet,] 


[Jan 4.19C8 73 

Cardiff Infirmary. Gknf.ral Hospital.— House Physician for six 
months. Salary £30, with board, residence, and laundry. 

Charing Cross Hospital.—A ssistant Physician. 

Chesterfield a»d North Derbyshire Hospital.—S enior House 
Surgeon. Salary £120 per year, with board, apartments, and 

Devonport, Royal Albert Hospital.— Resident Medical Officer, 
unmarried. Salary £100 per annum, with apartments, board. Ac. 

Enniskillen. Fermanagh County Hospital.— House Surgeon. 
Salary £52 per annum. 

Hartlepool# Hospital.— House Surgeon. Salary £100 per annum, 
with board, washing, and lodging. 

Hospital for Consumption and Diseases ok the Chest. Brompton. 
—Resident House Physicians for six months. Salary £25. 

Hull. Royal Infirmary.—T wo Casualty House Surgeons. Salary at 
rate of £60 per annum for six months and of £80 for 12 months, 
with board and lodging. 

Leeds Public Dispensary.— One Pathologist, Five Dental Surgeons, 
and Four ABS'Biant. Dental Surgeons, all honorary. 

Liykhpool Infectious Diseases Hospital.— Assistant Resident 
Meoical Officer, unmarried. Salary £120 per annum, with board, 
washing, and lodging. 

London Fkvkr H"»pital, Liverpool-road, N. — Resident Medical 
Officer. Salary £2oO per annum, with board and residence. 

London Lo« k Hospital, Soho. —House Surgeon to the Male Hospital. 
Salary £80 per annum, with board, lodging and * ashing. 

National Hospital for the Relief and Cure ok thb Paralysed 
ani> Epileptic. Queen-square, Bloomsbury.—Assistant Ptiysician 
for Out patients. 

Northampton General Hospital.— Assistant House Surgeon, un¬ 
married. Salary £60 per annum, with apartments, board, washing, 
and attendance. 

North Eastern Hospital for Children, Hackney-road, Bethnal 
Green. E.—Assistant Physician. 

Paddington Ghkkn Childrens Hospital, London, W.—Honorary 
Auers'hetist, also Honorary Radiographer. 

Portsmouth, Hoyal Portsmouth Hos htax.— Assistant House Sur¬ 
geon for six months. Salary at rate of £50 per annum, with 
board, Ac. 

Saint Georges Union Infirmary, Fulham-rond, London, S.W.— 
Second Assistant. Medical Officer. Salary £120 per annum, with 
board, residence, and washing. 

St. Mary’s Hospital Medical School, Paddington, W —Junior 
Demonstrator of Physiology. Salary at rate of £100 per annum. 

Sheffield, University of.—D emonstrator in Anatomy. Salary 
£150 per annum 

Somerset C»unty Council.— Chief Medical Inspector of Schools. 
Salary £500 per annum, with necessary out-of-pocket expenses. 

SURREY • ispensaRY, Southwark, S.E. - Physician. 

Swansea County Borough.— Medical Officer of Health. Salary £5C0 
per annum. 

Taunton Union. North Curry District.— Medical Officer. Salary 
£75 per annum and fees. 

University C llkgb Hospital, Gower-street, W.C.—Resident 
Medical Officer. 

Wadsley. near Sheffield, West Riding Asylum. —Fifth Assistant 
Medical Officer. Salary £140 per annum, rising to £160, with 
board. Ac. 

Warrington Union Workhouse.— Resident Medical Officer. Salary 
£lo0 ner annum and tees, with apartments, rations Ac. 

West-End Hospital for Diseases ok the Nervous System, 
Paralysis, and Epilepsy, 73, Welbeck-street, London, W. — 
Physician to Out-patients. 

West Ham Hospital, Stratford. E.—Junior House Surgeon for six 
mouths. Salary at rale of £75 per annum, with board, residence, 

Wrexham Infirmary.— Resident Medical Officer. Salary £80 per 
annum, with board, lodging, and washing. 

The Chief Inspector of Factories, Home Office, S.W., gives notice of 
vacancies as Certifying Surgeons under the Factory and Work 
■hop Act at Dron field, in the county of Derby ; and at Stratford, in 
the county ol Essex. 

Carriages, anb geatjjs. 


Sibley. —On Dec. 27th, 1907, at The Mansions. Duke-street, Orosvenor- 
square, W., the wife of W. Knowsley Sibley, M.A., M.D., of a 

Worthington.— On Dec. 29th, 1907, at The Sycamores, Birchington,, the wife of H. E. Worthington, M.R.C.S., L.R.C.P., of a 
daughter. _ 


Greenwood Penny—Phillips.— On,Nov. 14th. 1907. at St. James’s, 
Exeter, by the Rev. P. Williams, the Rev. W. David and the Kev. 
E. Reid, Sydney Greenwood Penny, M.R.C.S , L.R.C.P., of Pen- 
mene'h, Marazion, Cornwall, younger son of the late Robert 
Greenwood Penny of Nethergrove. Cbulmleigh. N. Devon, to 
Gvtpulllau Helen Leigh, younger daughter of the late Rev. James 
Phillips of Exeter. 

Jones-Evans —On the 1st inst., at Aherayron. Edmund Benjamin 
Jones, F R C.S-Eng , of * Chatswort h ” North End-road Golder’s 
Green, N.W., to lna Margaret, second daughter of the late 
Llewelyn Evans, of Pantclynhlr. New Quay, Cardiganshire. 


Garrod. —On Dec. 28th. 1907. at Harley-street. Cavendish-square, W., 
Sir Alfred B. Garn»d, M.D., F.It C P., F.H S., Phvsician Extra¬ 
ordinary to her late Majesty Queen Victoria, iu his 89th year. 

N.B.—A lee ol 5s. is charged for the insertion of Notices of Births, 
Marriages, and Deaths 

Soles, Styort Comments, aitb Jnstoers 
to Correspondents. 


In our issue of July 27th 1907, p. 240, we directed attention to the un¬ 
ventilated condition of the public telephone call offices and to the 
possible risk of contracting infectious disease while using them. In 
the construction of these call offices It is essential that external 
noises should be excluded as much as possible in order that the 
person who is inside may he able more easily to hear what is said to 
him from the distant station. Hence the difficulty of ventilation. 
The substance of our article was reproduced in Didaskalta, a 
periodical published In Frankfort, and Mr. Richard Goll of that city 
has consequently written to us that he Is the patentee of a system of 
ventilation which has been successfully applied to telephone call 
offices. According to the description which we have received it is an 
arrangement of tubes or conduits ( tine Anordnung von Leitungen) 
the action of which is noiseless and automatic, depending only on 
natural or accidental differences of pressure ( Luftdrnckunterschiede ). 
Particular attention is called to the fact that at the Hotel Marquardb 
In Stuttgart there are four telephone call offices ( Tclcpkon-jellcn) for 
the use of visitors, and the ventilation of these by Mr. Goll's system 
has given satisfaction. 


It is a good sign when human beings can appreciate humour. Not 
so very long ago a play of fancy was supposed to be incompatible 
with science. Science was regarded as a sober, solemn affair on no 
account to be treated lightly. Geniuses were seripus creatures of 
whom but a small minority could understand a jock and that, with 
<ieefficulty . To effect an entrance for a witticism into their surcharged 
sensoriums surgical opera'ions were a preliminary essential. We 
have been led to make these frivolous remarks by Captain J. Crawford 
Kennedy, R.A.M.C., who has successfully extracted “A Little 
Humour from the Malta Commission” for publication in the 
December number of the journal of his corps. At the risk of some 
of the allusions proving caviare to the general unfamiliar with the 
Internal economy of line regiments, we venture to reproduce the 
extract from an adjutant’s letter with which Captain Kennedy 
closes his article. 

Dear Kennedy, —P. has passed your note on to me, and all 
our men are now running about with butterfly nets, or trying to 
tempt the wily mosquito with lumps of raw meat, and I've 
indented for a small size of mouse-trap, but am doubtful if the 
Government will supply the necessary bait. Up to the present the 
bag Is one, and he si niggled bo w.hen our regimental poll e were 
effecting his capture that he had to be hit hard on the head ar.d 
I’m afraid Is almost, unrecognisable. PS.-Another capture just 
reported. We’ve put him in the guard room till your boxes arrive. 

He has been biting - and was consequently drunk and his 

capture was easy. Ought mosquitoes (when drunk) to have their 
boots removed ? 


In a recent number of t he Repertoire de Pharmacie M. P. Carles gives 
an interesting account of the use of sea-water in medicine. In 
addition to common salt sea water contains many important mineral 
substances, the totAl solid matter amounting to 3'2 to 3'8 per cent. 
Some of these substances are present only to an infinitesimal extent, 
but in biology the value of a substance is not necessarily dependent 
upon Its actual size or quantity. It has been shown that various 
marine plants have the power of extracting from sea-water minute 
quantities of compounds of iodine, bromine, arsenic, boron, 
manganese, lithium, fluorine, rubidium, crcsium, and other elements. 
Hence it was not unreasonable to suppose that t he higher animals 
might derive benefit from the assimilation of even minute traces of 
these physiologically active substances. The employment of sea¬ 
water as a remedial agent dates back to the time of Hippocrates, and 
modern physiological Investigations have led to its reintroduction inta 
medicine. Thus it has been shown that if a portion of the blood 
serum of a dog be replaced by an artificial serum the most suitable 
serum for the purpose is sea water, isotonic with the natural 
serum. Sea-water has been given by the mouth and by injec¬ 
tion with good results In cases of dyspepsia, loss of appetite, 
and tuberculosis. In general the appetite was improved and 
strength was rap dly regained. In order to obtain the beat and 
most immediate results it is necessary to observe certain 
precautions. The sea-water must be nat ural as it Is Impossible to 
imitate so complex a liquid. Indeed, it has been proved that sea 
salt, when r- -dissolved in distilled wat>r, lacks some of the 
properties of natural sea water, exerting a toxic action upon a dog 
when injected subcutaneously. It must be freshly collected, as It 
loses carbon dioxide on standing, with precipitation of some of its 
salts. It should be taken from the open boa remote from rivers and 
other sources of pollution. It should bo sterilised by filtration, as 
heat dissociates the bicarbonates and destroys the natural equilibrium 
of the liquid. When required for subcutaneous injootion it should 

74 The Lancet,] 


[Jan. 4, 1908. 

Thb Lancet,] 


[Jan. 4, 1908. 75 

Throat, Golden-square (9.30 a.if.), Guy’s (1.30 P.K.). Children Gt. 
Ormond-street (9.30 A.M.). 

At the Koval Kye Hospital (2 p.m.), the Royal London Ophthalmic 
10 A.M.), the Royal Westminster Ophthalmio (1.30 p.m.), and the 
Central London Ophthalmio Hospitals operations are performed daily. 


ROYAL SOCIETY OF MEDICINE, 20, Hanover-square, W. 

Thursday .—(Obstetrical and Qyiuecolorjical Section). 7.45 p.m., 
Dr. J. P. Uedley, Dr. Harold Siugton (introduced by Dr. 
Handheld-Jones), and Dr. A. H. N. Lea-era . Specimens. Mr. 
J. Bland-Sutton : On Carcinoma of the Ovary from a Clinical 
Standpoint. Dr. Carver and Dr. Fairbairn : On Haemorrhage 
into the Pons Varoiii as a Cause of Eclampsia. 

Friday.— (Clinical Section). 8.30 p.m.. Exhibition of Cases. Dr. 
Sidney Phillips: A Case of Fatal Illness in a Child with Post¬ 
mortem Appearances of the “ Status Lymphaticus.” The 
patients will be in attendance at 8 p.m. 

College, Millbank, S.W. 

Thursday.— 8.30 p.m., Major M. P. C. Holt, D.S.O. : The 
Advisability of Operation for Recurrence of Hernia in the 

General Hospital, Tottenham. N. 

Thursday. —4.15p.m. f Address Dr. Robert Hutchinson : Modern 
Theories of Diet in their Relation to Practice. 


Chenies-strect, W.C. 

Tuesday. —4 p.m., Dr. H. Campbell: Clinique (Medical). 

5.15 p.m., Lecture Dr. F. J. McCann: The Diagnosis and 
Treatment of Inflammation of the Fallopian Tubes. 
Wednesday. —4 p.m., Mr. Jackson Clarke : Clinique (Surgical). 

5.15 p.m.. Lecture :—Dr. Purvea Stewart: Psychasthenia. 
Thursday.— 4 p.m., Mr. Hutchinson: Clinique (Surgical). 

5.15 p.m.. Lecture : Dr. Beresford Klngsford: Some Special 
Methods of Administering Chloroform and their Relative 

Friday.— 4 p.m., Mr. C. A. Parker : Clinique (Throat). 

LONDON INSTITUTION, Finsbury-square, E C. 

Wednesday.—8.30 p.m.. Lecture:— Dr. Dundas Grant: Some 
Important Aspects of Suppuration of the Middle Ear. 

MENT, 7, Fitzroy square, W. 

Thursday.— 5 p.m., Opening Lecture :—Sir Thomas C. Allbutt, 
K.C.B.: Angina Pectoris (Post-Graduate Course). 

Leicester-square, W.C. 

Thursday. — 6 p.m., Lecture-.—Dr. M. Dockrell: Bullous and 
Vesicular Eruptions: I., Urticaria; II., Pemphigus; III., 
Pompholyx; lv.. Varicella. 

editorial notices. 

It is most important that communications relating to the 
Editorial business of The Lancet should be addressed 
exclusively “To the Editor, ’’ and not in any case to any 
gentleman who may be supposed to be connected with the 
Editorial staff. It is urgently necessary that attention be 
given to this notice. _ 

It ii especially requested that early intelligence of local events 
having a medical interest, or which it'is desirable to bring 
under the notice of the profession, may be sent direct to 
this offiee. 

Lectures, original articles, and reports should be written on 
mu side of the paper only, AND WHEN ACCOMPANIED 

Letters, whether intended for insertion or for private informa¬ 
tion, must be authenticated by the names and addresses of 
their writers—not necessarily for publication. 

We cannot prescribe or recommend practitioners. 

Local papers containing reports or news paragraphs should be 
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76 The Lancet, 


[Jan. 4, 1908. 

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Pharmaceutical Co., Loud., 
Manager of -, Mr. A Anderson, 
Northampton ; Dr. 1/ett Ander¬ 
son, Loud. 

B. -Mr. C. A. Ballance, Lond.; 
Major Blackham, R.A.M.C., 
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H. Butterfield, Northampton; 
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Dr. Q. D. M Beaton, Blackburn , 
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Superintendent of: Dr. B- M. 
Bernheim Baltimore. U.S.A.; 
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Henry Bartlett, Haaliugs; Mr. 
Joseph Bruton, Hove; British 
Medical Benevolent Fund, Lond., 
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Robert Boyle aud Sons. Loud.; 
British Me- ical Temperance 
Association, Enfield, Hon. Secre¬ 
tary of 

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Brighton, Mr. P. W. Clarke, 
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Lond.; Central London Throat 
and Bar Hospital, Secretary of; 
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Van Sickel, New York; Messrs. 

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Collie, Lond. 

D. —Dr J. L. Dick, Ayr; Lieu¬ 
tenant-Colonel C. M. Douglas, 
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K. Dixon. R.N., Louu ; Dr. 
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Derby, Secretary of; Mr. tf. 
Davey, Caterham Valley. 

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Editor of, Heatley Pateut 
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Haar and steinert, Paris, 
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Mr. H. Hilliard, Loud.; Messrs. 
C. J. Hewlett and don, Lond.; 
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tary of. Incorporated Institute 
of Hygiene Loud., Secretary of. 

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J. F. 

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S. Kutnow and Co., Lond.; Dr. 

K. M. Koury, Dueim, Sudan; 
Mr. S. Karger, Berlin. 

L. - Leslies, Ltd., Lond.; L. H.; 
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West Riding Medico-Chirurgical 
Society, Leeds, Senior Secretary 

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ton; Dr. J. Muir. Bellshill; 
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B Mr. J. A. Barth, Leipzig; 
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tralia; Sir Hugh Beevor, Bart , 
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wich ; Messrs. Brady and Martin, 
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head Borough Hospital, Hon. 
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Sons. Lond. 

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Lond.; D. G. G. M.; Dr. D. 
Douglas, Bellshill; Messrs. 
Duncan, Flockhart, and Co., 

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and Webb, Lond.; B. B. 3.; 
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Evans. Sons, Lescher, and Webb, 

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New South; Mr. C. J. 
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Handley, Lond.; Messrs. D. C. 
Heath and Co., Boston, U.S A.; 
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Messrs. C. Higbam and Son, 

J—Ur K. Jivanji, Secunderabad; 
Mr. T. J. JeukiuB. Henllan; 
The Jetter and Scheerer Co., 
Load., Manager of. J. H. B.; 
J. S..; J. M D ; J. M. 0.; J H. 
8. Messrs. Knox, Hassell, Dodd, 
and Co., Lond. 

L. Mr W W. Linney. Croydon; 
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Lacheur and Son, Lond.; Mr. 
W. Stuart Low, Lond.; Mr. 

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Dr. G. S. Middleton, Glasgow; 
Mr. W. Mair, Edinburgh. Mr. J. 
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Tokyo; Mr. R. Mosse, Berlin; 
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Morgan, Lond. 

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Mr. J. C. Neertes, Lond. 

O. —Dr. J. O'Connell, Mallow ; 
Professor W. Osier, Oxford; 
Dr. C. Ormerod, Burgess Hill; 
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culture, Accountant to the. 

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Dr. H. I. Pinches, Lond.; 
Messrs. Parker and Son, Oxford; 
Dr. J. H. Parsons, Lond.; 
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R. —Mr. R. P. Rowlands, Lond.; 
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Italy; Messrs. Kayner and 
Stuart, Camberley ; Mr. J. 
Reidy, Lond.; Mr. G. Q. Richard¬ 
son, Lond.; Dr. M. A. Buffer, 

S. — Dr. A. Silberman, Lucerne; 
Mr. G. A Stamper, Skegby; 
Dr. D. d'O. Soares, Lisbon; 
St. Mungo's College, Glasgow, 
Cashier to the; Major W. D. 
Sutherland, I.M.S., Jubbulpore, 
India; Dr G. Slight, Sandown, 
Isle of Wight; Professor T. 
Schott, Frankfurt; Dr. F. M. 
Sand with. Lond.; Sir Thomas 
Smith, Bart. Lond.; Mr. J. 
Stewart, Leeds; Mr. 0. Scholl, 
Liverpool. Mr. A Saunders, 
Lond.; Scholastic, Clerical, Ac., 
Association, Lond., Accountant 
to the; Mr. S. T Shlrvaiker, 
Bombay ; S., Tunbridge Wells ; 
Messrs. Spiers and Pond, Load.; 
Dr. T. B. Smith, Bellshill; Dr. 
F. J. Smith, Lond., Messrs. 
Scott and Bowue, Lond.; Dr. 
J. A. Shaw-Mackeuzie, Lond. 

T. Dr. K. J. Toye, Bideford; 
Messrs. E. B. Treat and Co. New 
York, Mr J. Thin, Edinburgh; 
Mr. L. S Taibot, Timaru; 
Messrs. J. Timpson and Co., 
Lond.; Mr J. Taylor, Grenada; 
Taunton and Somerset Hospital, 
House Surgeon of; Mr. W. 
Turner. Loud. 

U. Dr. H. A Upward, Romford; 
Mr. H. Upcott, Hull. 

V. —Dr. H E. Vincent, Horley; 
Mr. F. H. V. Voss, Stroud; 

V. M. B. 

W. Dr. T. Whitelaw. Edinburgh; 
Mr W. F. A. Walker, Dinas 
Mawddwy; W. V. G.. Surgeon- 
Colonel F. H. Welch. Lond.; 
Mr. C P. White, Withington; 
Dr. S. L. B. Wilks, Grassington; 
Dr. S. West., Lond ; W. B.; 
Dr. J. W. White, Glasgow; Mr. 
J. R. Webb, Footsnray, Aus¬ 
tralia; Messrs A. J. Wilson and 
Co., Lond.; W. H. S.; West¬ 
minster Hospital Medical School, 
Load., Secretary of; Mr. W. A. 
Ward, Richmond; Dr. W. H. 
Willcox, Loud. 

THE LANCET, January 11, 1908. 

% Jwtort 



Delivered at the Medical Qraduatei’ College and Polyclinic 
on Nov. 6th, 1907, 

By CHARLES R. BOX, M.D. Lond., F.R.C.P. 
Lond., F.R.C.S. Eng., 



Gkntubmkn, —Infections of the urinary tract in children, 
as in adults, may be classified as (1) descending infections, 
(2) ascending infections, and (3) infections by contiguity. 
The following remarks refer to the ascending and descending 
infections only. 

Defending infection is synonymous with infection carried 
to the kidney by the blood-stream and is often termed 
“ bsematogenoos ” for this reason. In certain cases of this 
variety of infection the kidney presents evidence of very 
gross disease. Renal infarction such as may occur daring 
the coarse of malignant endocarditis is an instance in point. 
Infective emboli may become impacted in the interlobular 
arteries, thrombosis and infarction result, organisms derived 
from the infected embolus invade the necrotic area and may 
make their appearance in the urine. The presence of a 
wedge-shaped infarct is not, however, infallible evidence that 
the infection is hsomatogenous, for infarcts of similar shape 
but limited to the pyramids or their extensions may arise as the 
result of Infections of an ascending character. In the course 
of general tuberculosis, too, macroscopic lesions of the kidney 
occur. This hsomatogenous infection gives rise to miliary 
lesions which appear in the perivascular connective tissue 
and are visible to the naked eye, whilst microscopical 
examination may also reveal the occurrence of “ excretion 
tuberculosis,” the bacilli passing through the glomerular 
tufts and infecting the interior of the urinary tubules into 
which they are extruded. It seems that the excretion of 
organisms by the kidneys occurs in other diseases also, and 
that the process may give rise to undue irritability of the 
urinary tract and even to evident pyelitis or cystitis. As 
examples of this process the bacilluria of typhoid fever and 
the occurrence of pyelitis or of transitory incontinence of 
urine in such diseases as measles, scarlet fever, diphtheria, 
and small pox may be quoted. But it is a remarkable fact 
that in many of the cases of bacilluria associated with 
typhoid fever, scarlet fever, measles, and diphtheria the 
organism present has on proper investigation been found to 
be the bacillus coli communis. 

There is, then, clinical evidence that the urinary tract may 
be the site of descending invasion. But it is important from 
the point of view of the prevention and treatment of urinary 
infections to inquire whether the common invasion in child- 
hood is really of a descending character. Conheim suggested 
that In the event of a general bacterial invasion the body 
protected itself by the secretion of living germs through the 
intact kidney, thus relieving the system from the noxious 
organisms. A point of such importance inspired observations 
by many other observers and amongst them Professor C. S. 
Sherrington has shown that, although it is true that certain 
organisms when injected into the blood may escape in this 
way, yet the excretion is neither rapid nor immediate and, in 
the case of innocuous organisms, may not take place at all. 
The inference is that it is only after a certain amount of 
damage has been inflicted on the renal secreting tissues that 
the escape of organisms takes place. When blood is present 
in the urine after such experiments it may be assumed that 
gross damage has occurred. The presence of a quantity of 
albumin may have the same significance but even in the 
absence of hsematuria or of albuminuria it cannot be assumed 
that some damage has not been inflicted on the kidney. 

The matter appears to stand thus : The body can dispose 
of enormous numbers of iojected bacilli without their 
appearing in the urine or other secretions. When they do 
appear the time of their appearance and the substances which 
appear with them lead to the presumption of renal damage. 
Tlie quantities which appear in the urine are not in any way 
comparable to the quantities injected. Now clinically, in 

No. 0402. 

cases of bacilluria, the organisms appear in the urine, even 
when freshly voided, in enormous numbers. It is quite the 
exception to obtain any definite evidence of renal damage in 
the form of casts or blood and, as already stated, the bacill¬ 
uria of typhoid fever, of scarlet fever, of measles, and of 
diphtheria has in many cases been proved to be a colon 
bacilluria. These facts lead to the suspicion that after all 
the common cause of bacilluria is due to an ascending 
infection, a suspicion which is corroborated by the sex 
incidence of the disease, for many more cases occur in 
females than in males. In some instances, too, the chrono¬ 
logical order in which bladder and kidney suffer admits the 
same explanation. 

Aicending infection .—In the adult the importance of 
ascending infection has long been recognised, but there can 
be no doubt that in childhood infections of this kind are 
muoh more common than ordinsurily is supposed. When atten¬ 
tion is seriously directed to the possibility of their occurrence 
a notable advance in preventive, if not in curative, treatment 
will have been made. The actual track of ascending urinary 
infections in the adult has been much discussed. Owing to 
the trivial character or even absence of lesions in the ureter 
some have supposed that the infection is carried either along 
the lymphatic channels which accompany the latter or 
directly through the chain of anastomising arteries or veins 
which link the bladder with the kidney, or even indirectly 
from the bladder to the kidney in the form of a true bsemato- 
genous infection. The lymphatic connexion between the 
bladder and the kidney appears to be neither free nor direct. 
Experimental injection of the connecting lymphatics is 
difficult and their exact pathological importance is as yet 
undetermined. There is also but little evidence to offer as to 
the part played by the anastomotic vascular links. The 
links in question consist of the chain which accompanies 
the ureter and also, in the female, of a chain forms d 
by the anastomosis of the vesical, uterine, ovarian, 
and renal vessels. There are experiments which appear 
to show without doubt that an induced cystitis with 
injury to the bladder can infect the kidney through the 
general circulation, for after excision or ligature of one 
ureter the corresponding kidney has become converted into a 
pyonephrosis in consequence of artificial infection of the 

But the ureter itself is commonly, and I believe 
rightly, looked upon as the highway of infection. It is 
generally acknowledged that ascending infection is to be 
expected where the ureter is blocked by a calculus, or where 
disease of its intravesical portion interferes with its efficient 
closure against reflux, or where there is obstruction to the 
outflow from the bladder. But the conditions here postu¬ 
lated are uncommon indeed in childhood, save in the csBe 
of boys with a tight prepuce, and, moreover, the infection 1 b 
more common in girls. The chronological sequence of 
bladder infection and renal infection in some cases has left 
no doubt in my own mind that the colon bacillus can prod nee 
an ascending infection apart from obstruction to the descend¬ 
ing urinary stream, a process which may be aided by its 
motility, as has often been suggested. Quite recently, too, 
it has been stated that ascending tuberculosis of the kidney 
can be experimentally produced by injecting an emulsion of 
the bacilli of bovine tuberculosis into the bladder with¬ 
out interrupting the flow of urine. The observations of 
Ur. C. J. Bond on the ascending currents in mucous canals 
are of interest in this connexion. He succeeded in demon¬ 
strating by the use of sterilised pigment that colouring 
matter deposited in the entrance of the urethra is carried 
by ascending currents into the bladder and that pigment 
deposited in the bladder Is in like manner conveyed to the 
pelvis of the kidney. But it must be admitted that a normal 
condition of affairs did not obtain in his experiments, for 
they were carried out in patients in whom by reason of 
cystotomy or nephrectomy the normal downward flush of the 
urinary passages had been interfered with. 

Nature and traclt of the amnion infection of childhood .— 
There is no doubt that in children the commonest infection 
of the urinary tract is that which is due to the colon bacillus. 
This has been the experience of all who have investigated this 
subject, and their conclusions I can, from my own observa¬ 
tions, confirm. Although the disease may occur in males it 
is much more common in females, which is strong corrobo¬ 
rative evidence of its ascending character, for the shortness 
of the female urethra and the proximity of its orifice to the 
anus render infection easy. In babies infection through the 
urethra may occur from soiled napkins or from the passage 


of stools over the vulva. The presenoe of colon bacilli in 
the urine of infants suffering from diarrhceal diseases has 
been demonstrated by Trumpp. His proportions were two- 
thirds females and one-third males, a very significant 
preponderance of the females. In older children faecal 
contamination of the vulva must often take place, 
and is occasionally very obvious in the case of children 
brought to the out-patient department of the hospital. 

I have been surprised to find how often the colon 
bacillus is present in the urine of children suffering from 
thread-worms. Occasionally the ova of the parasites, and 
sometimes also the worms themselves, are found in the urine 
together with the bacilli. The coexistence of the bacilluria 
with the presence of the parasites in the bowel suggests that 
the worms may be in some way accountable for the urinary 
infection, either by the irritation and consequent scratching 
which they indace or possibly by acting as carriers of the 
bacilli from the anus to the vulva. It may be that the bene¬ 
ficial effect of circumcision in certain cases of incontinence 
of urine in the male is not so much due to the removal of 
mechanical irritation as to the abolition of a nidus of 
bacillary infection. I have also found that cases of colon 
cystitis and of pure bacillnria are much more common than 
cases in which the signs of pyelitis are present. This also 
appears to indicate that the infection is an ascending one. 
The facts bearing on ascending infection have recently been 
emphasised by H. Lenhartz who, investigating the cause and 
incidence of pyelitis in the adult, found that 66 out of 80 
cases were due to invasion by the bacillus coli communis and 
that males were rarely infected. He attributed much Im¬ 
portance to pregnancy, parturition, and menstruation in pre¬ 
paring the soil—conditions which naturally do not obtain in 

There are certain characteristics of the colon bacillus 
which are noteworthy and which, in some degree, explain 
the clinical manifestations of the infection. It is an organism 
which, although it grows by preference in alkaline or just 
neutral media, can also grow in acid urine and is not easily 
got rid of by altering the urinary reaction. The acidity of 
urine is inimical to many other microbic infections, hence 
the bacillus coli is often found in pure culture. In the 
second place, it does not decompose urea and so give rise to 
ammoniacal products which have a destructive influence on 
urinary epithelium and usually co-exist with the more severe 
forms of purulent inflammation. Writers have remarked with 
surprise that in urinary infections due to the colon bacillus 
vulvo-vaginitis is seldom present; stress has also been laid on 
the fact that in colon cystitis and colon pyelitis the inflam¬ 
mation as a rule is of a very superficial or catarrhal nature. 
Lastly, the organism is motile, and so may, without the 
assistance of urinary stagnation, make its way into the 
pelvis of the kidney. 

That acute ascending infections of the urinary tract may 
occur in adults suffering from gonorrhcea is undoubted. 
Whether these infections are due to the gonococcus or to 
the colon bacillus I am not in a position to state, but 
mention the fact of their occurrence because gonorrhoeal 
vulvitis is not unknown in little girls, and it would be well if 
cases of ascending infection in this disease were properly 

Clinical manifestations .—Infection of the urinary passages 
in childhood may manifest itself as pyelitis, cystitis, or 
incontinence of urine without obtrusive evidence of local 

Pyelitis may occur as a febrile affection with sudden 
onset, chills, and pyrexia. The temperature chart may show 
marked daily fluctuations or closely resemble that of pneu¬ 
monia, or in some cases take the form of a succession of 
short febrile periods with intervening intervals in which 
the temperature is practically normal. The temperature 
may rise as high as 105° F. At the onset of the attack 
a certain degree of suppression of urine may occur, but 
may later on polyuria is the rule. The quantity, it is said, 
be increased to twice or thrice the normal, and frequent 
reflex micturition without evidence of cystitis is sometimes 
met with. When the course of the disease is protracted 
emaciation rapidly occurs. Enlargement of the spleen 
may often be detected and sweating may be pronounced. 
As a rule, the local manifestations of the disease are 
unilateral, and the right kidney is more likely to be 
affected than the left. Fain may be complained of and when 
present is generally subcostal and not lumbar in position. 
But the kidney may be found to be definitely tender and 
even enlarged in patients whose pain is trivial. The pain 

appears to be most severe in those in whom a certain degree 
of hydronephrosis has been induced by the disease. It is 
remarkable how quickly the renal enlargement may subside. 
The distension of the renal pelvis cannot be due to a twist¬ 
ing of the kidney, for undue renal mobility is extremely rare 
in infants and young children. It is possible that inflam¬ 
matory swelling of the mucous membrane of the pelvis, at 
its junction with the ureter, is the cause of the condition, 
for at this point the passage is naturally constricted. I 
believe that pyelitis occasionally occurs in a much milder 
form, characterised by very transitory attacks of subcostal 
pain with little or no fever. My reason for this belief is that 
more than once I have known such attacks of pain to occur 
in patients with colon bacilluria who were under treatment 
for incontinence of urine. 

Blight vulvitis is present in some cases of pyelitis and in 
some there have occurred symptoms of cystitis, in the form 
of painful, frequent micturition and hypogastric tenderness, 
before the actual onset of the pyelitis. The urine is usually 
acid and slightly turbid or opalescent. A slight sediment 
falls ; it consists of a few pus cells. In the more acute cases 
some erythrocytes and even a few hyaline casts may be seen. 
The presence of many tube casts indicates coincident inflam¬ 
mation of the kidney. The amount of albumin is slight and 
a certain amount of nucleo-proteid can be demonstrated by 
suitable tests. The turbidity of the specimen does not clear 
up with boiling or with acids and persists after repeated 
filtering. It is due to the presence of bacilli which almost 
invariably turn out to be the common colon organism. It is 
possible that repeated attacks of pyelitis of this nature may 
account for some of the cases of hydro- and pyo nephrosis 
which are found in adults and for which no obvious cause is 

The possibility of the presence of pyelitis should always 
be borne in mind when dealing with cases of obscure fever in 
childhood, whether of a sustained, remittent, or relapsing 
character. The occurrence of shivering or of rigors should 
especially direct attention to the urine and urinary tract. 
More than one specimen of urine should be examined, as it is 
not every portion obtained which shows the characteristic 
changes. The fever is sometimes erroneously attributed to 
gastro-intestinal disturbance, to deep-seated pneumonia, or 
even to tuberculosis. In malarial districts malaria may be 
closely simulated. 

Cystitis of a more or less acute character is not at all un¬ 
common in childhood The onset as a rule is sudden and not 
attributed to any definite cause ; but in some instances, as in 
adults, the symptoms appear to follow exposure to cold and 
in a few cases, of which I have met with instances, the 
attack has followed trivial injury to the perineum, such as, 
for instance, may be inflicted by falling astride a chair. In 
a severe case the temperature may rise to 103 d or more. 
Micturition is frequent and painful. Nocturnal incontinence 
of urine usually sets in. The child screams during the 
passage of urine and attempts to evade the act, often 
tightly crossing the legs. Pain is referred to the hypogastric 
region, the fronts of the thighs, and sometimes to the 
perineum. These regions may be decidedly tender. In 
some cases the act of micturition is accompanied by distinct 
rigors. A little blood may escape with the urine and in one 
of my patients the bleeding was so obvious that the mother 
volunteered the statement that the clothes were stained just 
as if the child (a little girl) were unwell. 

Just as with pyelitis, milder attacks occur in which there 
is no fever and the pain on micturition and tenderness of 
the bladder are very slight. The increased frequency of 
passing urine is the chief feature of these cases. The urine 
is faintly acid or neutral; it is important to recognise 
that the urine may remain acid both in pyelitis and 
cystitis, especially when the infection is due to the 
colon bacillus. It is always turbid or opalescent; if much 
blood is present it may be smoky. The amount oi albumin 
is variable ; sometimes it is considerable and may lead to a 
fear that the kidney is involved, but nevertheless entirely 
clear up. As in pyelitis and other conditions some nucleo- 
prcteid may be present. The sediment contains pus cells, 
sometimes blood corpuscles and epithelium ; in very acute 
cases membranous flakes may occur. The colon bacillus 
is almost invariably found. Needless to say, a proper 
bacteriological examination is essential for correct dia¬ 
gnosis. Abrupt stoppage of the stream during micturi¬ 
tion should always suggest the presence of stone and 
lead to farther examination by bimanual palpation of the 
bladder, x ray examination, and sounding. The possibility 


of the stone being in the ureter or impacted in the com¬ 
mencement of the urethra should not be overlooked. The 
stream is sometimes stopped by reason of the intense pain in 
cystitis, but not abruptly, save possibly in the oases where 
large membranous shreds are present. Frequency of 
micturition occurs both in pyelitis and cystitis, but actual 
pain on micturition with tenderness above the pubes and in 
the perineum point to involvement of the urinary bladder. 
No differential value appears to belong either to the charac¬ 
ters of the epithelium or the amount of albumin present. 

Incmtincnce of urine, as is well known, may be associated 
with bacilluria, and again the organism present is almost 
invariably the bacillus coli communis. Some of the most 
inveterate cases of bed-wetting with which the physician is 
called to deal fall into this group, whilst, on the other hand, 
some of the cases in which the same organism occurs are 
quite mild and transitory, yielding readily to the simplest 
treatment. That in some instances the incontinence may 
greatly improve, although the organisms are still present, is 
also noteworthy. In inveterate cases the urine is always 
turbid from the presence of myriads of bacilli. In a few 
cases the urine is not decidedly opalescent but colon bacilli 
are found in large numbers in the somewhat flocculent cloud 
which quickly settles in the urine glass. Increase in quantity 
of the urine has generally attracted the attention of the 
mother and is usually remarked upon. The incontinence at 
first is nocturnal only and the bed may be wetted two or 
three times each night. In some instances diurnal incon¬ 
tinence sooner or later ensues ; in a few of my patients it has 
assumed that form in which urine escapes on coughing, 
aughing, or other physical exertion. 

The reaction of the urine is generally faintly acid, some¬ 
times neutral, never, in my experience, alkaline. A mere 
trace of albumin may be present by the boiling test. 
The centrifugalised sediment consists of a few pus cells 
and many bacilli. Casts of any sort are absent and 
the presence of urinary epithelium is quite the exception. 
Sometimes a few oxalate crystals are noted. I have once or 
twice met with the decomposition, with production of a 
curious odour described as “ fishy,” which is attributed by 
some authors to colon infection. In incontinence with 
marked bacilluria it is exceptional to obtain a history 
pointing definitely to cystitis or pyelitis but slight vulvitis is 
present in some instances. Exceptionally a history of supra¬ 
pubic pain at some stage of the affection may be elicited and 
some of my patients have had definite attacks of slight sub¬ 
costal pain whilst under treatment, which may indicate the 
presence of slight pyelitis. For some time past I have been in 
the habit of testing the urine of these cases for nucleo-proteid, 
the presence of which is assumed to indicate some irritation 
of the urinary tract. For this purpose Ott’s method has been 
adopted and the reaction is often well marked, but a similar 
reaction occurs in the urine of many other children who have 
no bacilluria. 

There is a curious resemblance amongst most of the 
patients who suffer from this form of incontinence—they 
are shy and nervous and frequently get the reputation of 
being stupid or sullen. This mental condition is much 
improved when the disease yields to treatment. Headaches 
are frequent, the tongue generally is coated, and the bowels 
are irregular in their action. A history of attacks of 
diarrhoea is not uncommon, but I have not been able to 
satisfy myself as to the condition of • ‘ coprostasis ” on which 
some authors lay so much stress. It is true that in some 
cases the abdomen is somewhat distended and tympanitic 
but this may be seen even when the bowels are acting quite 

The course of the disease appears to be not altogether 
afebrile. Slight elevation of temperature at night, rarely 
above 100° F., may occur for weeks at a time. The presence 
of worms together with bacilluria is not uncommon and, as 
already suggested, the connexion between the two conditions 
may possibly be one of cause and effect. The evidence of 
mothers as to the presence or absence of worms is frequently 
unreliable and in several instances their presence, though 
unsuspected, has been proved by the discovery of ova or 
even of worms themselves in the urine. 

Prognoti ».—The cyBtitis of childhood when caused by the 
colon bacillus calls for a guarded prognosis. A certain 
number of cases, particularly those with acute onset and 
marked bladder symptoms, clear up under the simplest 
medicinal and dietetic treatment. There are others, however, 
in which the local symptoms may be less pronounced, which 
drag on with intermissions and exacerbations, sometimes for 

months. Pyelitis due to the colon bacillus appears to be 
much less common than cystitis. My cases have been few in 
number and short in duration but if any parallel existB with 
similar cases in the adult the affection should vary 
considerably both in duration and intensity. The cases of 
incontinence of urine with which the colon bacillus is 
associated also vary very widely. In some cases the 
symptoms are transitory and clear up without any special 
treatment; others, as already indicated, resist all methods of 
treatment with the greatest obstinacy. The marked variations 
in the clinical course of these infections must be due either 
to variations in the virulence of the infecting organism or, as 
I believe is more probable, to variations in the resisting 
power of different individuals. 

Treatment .—If the theory of ascending infection be correct 
the importance of frequent bathing and of the avoidance of 
urethral contamination from the anus as preventive measures 
cannot be overrated. All cases of vulvitis should be recog¬ 
nised promptly and treated. The milder cases of cystitis, 
pyelitis, and incontinence of urine do well with the ordinary 
treatment by full doses of citrate of potassium combined with 
the sedatives of the belladonna group. In the treatment of 
severe cases of incontinence of urine, even though colon 
bacilluria is associated, the first care should be to determine 
the presence or absence of thread-worms. Careful examina¬ 
tion of the stools and urine is necessary for this purpose. 
The ova and embryos should be sought for, the former being 
easily recognised by their asymmetry, being flattened on one 
side. I do not propose to discuss the treatment of these 
parasites beyond saying that when injections are used for 
this purpose the proper time to give them is not necessarily 
at night or morning but after the howelt hare acted. 
Belladonna has proved a very disappointing drug in inveterate 
cases. I have not hesitated to push it until delirium was 
induced and even then it has failed. Neither have I been 
able to obtain any definite results with drugs of the formalin 
type, such as hexamethylene tetramine (urotropir.e) or its 
methylene citrate (helmitol) or its benzoyl derivative 
(hetraline). These drugs, although very effectual against 
the typhoid organism, do not appear to influence the colon 
bacillus. The results obtained with benzoate of ammonium, 
salicylate of sodium, and boric acid are no more encouraging. 
The latter in particular plays havoc with the appetite and 
soon induces nausea. 

With a view to test the theory that the bacillary infection 
is hmmatogenous and perhaps due to coprostasis, cases were 
treated for prolonged periods with mistura olei ricini (B.P.) 
and also with calomel to the point of producing slight stoma¬ 
titis. No improvement could be ascertained. Salol also failed. 
In one case of colon bacilluria and incontinence, after 
internal medication had failed, it was accidentally discovered 
that the use of boric powder to the vulva always stopped the 
incontinence. The same treatment was not successful in 
other cases. 

Finally, with the cooperation of Mr. L. S. Dudgeon the 
effect of anti-bacillus coli serum was tried. In one patient 
with inveterate colon bacilluria and incontinence, where the 
condition had resisted all treatment for 12 months, admission 
to hospital and three injections of 25 cubic centimetres of the 
serum stopped the incontinence although the bacilluria per¬ 
sisted in some degree. This patient relapsed, to the extent 
of one incontinence a week, a month after discharge, but she 
is much better than before the treatment was adopted. At 
one period she suffered from thread-worms. In another 
patient treatment with the serum both by subcutaneous injec¬ 
tion and by rectum failed after a prolonged trial. Dr. M. A. 
Cassidy carried out a series of vaccinations with no better 
result. On washing out the bladder with saline solution 
and leaving in 25 cubic centimetres of the serum daily for 
seven days the urine cleared in an extraordinary way and 
cultures were only with difficulty obtained from it. But the 
incontinence persisted and a few days after discontinuance 
of the treatment the bacilluria was as pronounced as ever. 
In the same patient irrigation with boric solution and also 
with quinine had practically no effect. Thread-worm 
embryos were found on microscopical examination of the 
fasces although their presence could not be determined in 
any other way. The case is still under observation. 

My acknowledgments are due to Mr. Dudgeon, the super¬ 
intendent of the clinical laboratory at St. Thomas’s Hospital, 
and also to Dr. P. N. Panton for the ungrudging assistance 
they have afforded me in the investigation of the bacteri¬ 
ology of a long series of cases on whioh this lecture was 

b 2 

80 The Lancet,] 


[Jan. 11,1908. 

Some Juntarlis 



Bciixtj an Address delivered at a Meeting of the East Yorks 
JJivision of the British Medical Association at Hull 
on Nov. 15th , 1907 , 

By A. T. BRAND, M.D.Aberd., V.D., 


Mr. President and Gentlemen, —The problem, “What 
is Cancer ! ” is hoary with antiquity, yet, nevertheless, it is 
of perennial interest. On two previous occasions I have had 
the honour of addressing you upon this subject; once on its 
“Etiology,"' and again on its origin by “Exogenesis.”* 
To-night 1 desire to direct your attention to certain points to 
which I have not previously referred, and to others already 
mentioned, but whioh 1 wish to enlarge upon and emphasise. 
That the importance of the problem is vital will be admitted 
by all, for, although many other diseases are just as in¬ 
curable, and exact even a greater tale of victims than cancer 
does, there is do disease which is so universally dreaded, or 
causes more mental distress, in addition to physical suffer¬ 
ing. This importance, moreover, becomes still greater when 
it is realised that the disease is becoming more and more 
widely diffused—that it is unquestionably increasing. 

The Increase of Cancer. 

An appeal to statistics leaves it in doubt whether the 
percentage ratio is or is not increasing, although the con¬ 
sensus of expert opinion is in favour of increase. No doubt 
the percentage ratio is affected by the greater accuracy in 
diagnosis and by the fact that the average duration of life is 
markedly increased, but it must not be overlooked that many 
deaths have been certified as due to malignant disease 
which have not been confirmed by sectio cadaveris. Even, 
however, if the percentage ratio is not increasing but 
remains stationary, it is still evident that cases of cancer 
must increase in number, pari pas tv with the increase in 
population. When, therefore, the population of a given 
place doubles itself, as it does in x years (Vienna, e.g., has 
doubled itself in 25 years), then the number of cases of 
cancer must likewise, at the end of this period, be double 
what it was at the beginning. 

Dr. S. Monokton Copeman states 3 in the Guthrie lecture, 
delivered in 1907 at Westminster Hospital, presumably from 
reliable data, that of individuals at present living above the 
age of 35 years, 1 in 8 women and 1 in 12 men will 
eventually die from cancer. This means that cancer will 
decimate those of an age above 35 years—truly an appalling 
prospect 1 

I regret that I am able to corroborate this estimate of Dr. 
Copeman from statistics supplied by my own practice. 
During the last five years there have been 389 deaths 
certified, of which 44 have been due to cancer (17 males and 
27 females), and this yields an annual average of 11'3 per 
cent, of deaths due to malignant disease. The actual figures 


Due to Cancer. 

1903 .... 

..66 deaths . 

5 (4 females, 1 male) . 

7'5 per cent. 

1904 .... 

... 78 „ . 

14-1 „ 

1905 ... 

... 99 . 

8 (5 females, 3 males) . 

80 „ 

1906 .... 

... 72 . 

7 (6 females, 1 mate) . 


1907 ... 

... 74 . 

13 (6 females, 7 males) . 

17-56 ,. 


Between 40 and 50 years 

... 2 

Between 80 and 90 years... 


50 60 

... 11 

Above 90 years 

... ... ... 



60 „ 70 „ 

... 12 



70 80 „ 

... 13 


... ... ... 


Youngest, 48 years ; oldest, 94 years. 

Region . 

Internal (mouth—rectum) . 24 

Breast . 9 

Genito-urlnary . 6 

Intracranial . 1 

Face and groin . 4 

Total. _, ... 44 

Under observation, 5. 

* The superior figures refer to the bibliography at the end. 

Cancer Hypotheses. 

Since the causa causans of cancer has not yet been demon¬ 
strated, it is not remarkable that many causes should have 
been suggested and many hypotheses propounded. Indeed, 
such causes and hypotheses are countless, and while their 
attempted recapitulation would doubtless be of great interest 
such wonld be but vain iteration. Suffice it to say that all 
these alleged causes and suggested hypotheses crystallise out 
into two classes : (1) intrinsic, of which the number is 
“legion”: and (2) extrinsic, of which there is but one. 
Autogenesis or Exogenesis.' “that is the question.” No 
doubt the calm, philosophic, and scientific attitude to main¬ 
tain npon a subject which cannot be proved to demonstration 
is that of “the open mind ” ; bat even the calmest, unless he 
is a disinterested Gallio, must find it hard to remain in a 
state of passive imperturbability when so much is at stake. 
Hence it is that there are warm advocates of both these views. 
The exponents of exogenesis believe that the evidence in 
favour of the extrinsic origin of cancer is overwhelming, and 
that this hypothesis will satisfactorily account for tbe 
incidence of cancer in every case, and they acknowledge 
only one possible cause—viz., parasitism. The believers in 
autogenesis, on tbe other band, chiefly maintain a negative 
attitude, denying tbe possibility of an extrinsic cause, bnt 
fail to formulate any practicable hypothesis which will 
explain the origin of the disease in every case. They suggest 
theory after theory, continually shifting their ground, and 
nohow can they suggest satisfactorily why cancer should 
arise, apparently do novo, in any single case. 

Again, the supporters of exogenesis hold that if cancer has 
an intrinsic origin—e.g., “running to seed”—it would not 
only be very much more prevalent than it is, but that 
few, if any, could escape from it. They also hold that 
an extrinsic origin would satisfactorily account for the pro¬ 
portion of individuals attacked, and believe that the wide¬ 
spread occurrence of the disease among vertebrates indicates 
the omnipresence of a specific parasite, and that those who 
are attacaed are simply those whose vulnerability, from what¬ 
ever cause, has permitted its access to the host and favoured its 
development. The opponents of exogenesis urge that the 
extrinsic origin of cancer is impossible because it is not 
entirely analogous to any known infectious disease. Tbe 
reply to this is that it is most unreasonable and illogical to 
presume that pathological processes can be in any way 
limited or even influenced by analogy ; and, furthermore, 
that analogy is quite incapable of proving anything. At the 
most, analogy can suggest mere probability, and is, after all, 
only a very convenient method of comparison between pro¬ 
cesses which resemble one another. 

The following may be cited as a concrete example of tbe 
futility of trusting to analogy to establish a conclusion. 
When Farmer, Moore, and Walker announced their interest¬ 
ing discovery that the karyokinesis of the cells forming a 
malignant neoplasm is heterotype in character, and that tbe 
karyokinesis of the cells of normal reprodnetive tissue is 
also heterotype, the director of the Imperial Cancer Research 
Institute ' hastened to emit the extraordinary declaration, 
ex cathedra, that “malignant new growths were virtually 
reprodnetive tissue arising in abnormal situations ” 1 

Now, which hypothesis is most probably right—autogenesis 
or exogenesis 1 It is difficult, and even impracticable, to 
disenss tbe former, since the various Intrinsic hypotheses are 
too numerous and too elusive, while their very multiplicity 
testifies to their inadequacy, but exogenesis, having only 
one string to its bow—viz., parasitism—can be considered. 
If further information regarding these numerous intrinsic 
hypotheses and suggested causes of cancer iB desired, I 
wonld refer yon to a work recently written by Dr. Jacob 
Wolff of Jena, entitled “ Die Lehre von der Krebskrankheit 
von den aeltesten Zeiten bis Gegenwart ” (“ The History of 
Cancer from Ancient Times to the Present ”). It was pub¬ 
lished in 1907 by Gustav Pischer and consists of 747 octavo 

Since cancer is admittedly a specific disease which runs 
a definite course of attack, extension by dissemination 
similar to that of many other diseases, such as tubercle, 
syphilis, malignant endocarditis, Ac., constitutional intoxica¬ 
tion, and ending only in death, believers in exogenesis 
cannot admit the possibility of any somatic cell spon¬ 
taneously developing specific malevolent action. They are 
constrained to believe that a specific disease can no more 
originate without the presence of a specific morbific agent 
than that parthenogenesis can ocenr in tbe vertebrata. This 
specific agent, they consider, cannot be other than an 
extrinsic parasite, either a microphyte or a microzoon. 

The Lancet,] 


[Jan. 11, 1908 . 81 


It may truly be said of parasitism what Shakespeare ' says 
of Cleopatra, by the mouth of Enobarbus. “Age cannot 
wither her, nor custom stale her infinite variety.” The 
universality of parasitism is quaintly but concisely expressed 
in the quotation from Professor Russell Lowell 

“ Great fleas have little fleas 

Upon their backs to bite ’em ; 

And little lleas have lesser fleas, 

And so ad infinitum." 

What is true of the pulex irritans is equally true of all 
creation. The diseases which we already know to be caused 
by parasites are very numerous, and so many more are 
becoming suspected of a like origin that presently one will 
be driven to conclude that all the ills to which fiesh is heir, 
excepting accidents, are due to parasitism. Organic chemistry 
has been defined as “The continued history of carbon,” It 
appears that we shall soon be justified in defining all 
disease (apart from accidents) as "The continued history of 

Is Cancer Infectious? 

If cancer is caused by a parasite it comes under the 
designation of “infectious." Is oanoer infection*/ Before 
answering this question, which is the theme of this essay, it 
were well to define what I mean by the terms “ infection ” 
and “infectivity.” “Infection” iB a comprehensive term 
and may be defined as the transmission of a disease from 
one individual to another, directly or indirectly, by the 
agency of a specific micro-organism, either a bacterium or a 
protozoon. I believe cancer to be thu* transmissible. Infec¬ 
tion varies greatly in degree, and cancer is evidently not 
infectious to the same extent as many other diseases— 
e.g., variola. It is probably acquired much as enterics is by 
introduction through the mouth; or as syphilis is, by 
contact; or as tetanus is, by access of the germ to any 
vulnerable part; or it may be through the agency of an 
intermediate host, as is the case in malaria or trypano¬ 

It has long been maintained, and many concrete instances 
have been quoted to prove, that cancer is transmissible by 
direct contact, ae in “cancer-iVdeux,” of which “coition- 
cancer” is an example. Such transmission, however, has 
been generally denied and accounted for by fortuitous 
coincidence ; but as transmission by implantation from one 
lower animal to another of the same species has been 
successful, and freely admitted to be so by all, the trans¬ 
mission in the case of “ cancer-i-deux ” has had reluctantly 
to be admitted as at least possible. This transmission has 
been designated “transplantation” and not admitted to be 
the successful and genuine inoculation of a specific disease. 
Now, if the “transplanted” cancerous tissue resembled a 
skin graft, always remaining local and forming no tumour, 
or if it merely continued to grow locally by proliferation 
without the usual metastatic dissemination and constitu¬ 
tional intoxication, and never caused death, then the term 
“transplantation ” might be justified ; but when the charac¬ 
teristic evolution of malignant disease follows, terminating 
the life of the invaded host, one can only regard the case as 
one of genuine inoculation of a specific disease by a specific 
agent—i.e., that it is the result of true “infection.” 

In connexion with the successful inoculation of cancer in 
the lower animals of the same species, and also as bearing on 
the question of “cancer houses and rooms,” an interesting 
communication was made by Dr. Gaylord of Buffalo entitled, 
“Evidences that Infected Cages are the Source of Spon¬ 
taneous Cancer developing among small Caged Animals.” 8 
I regret that the time at my disposal is too short to permit 
of reference to this paper at length, but I am sure you will 
find it well worthy of perusal. Dr. Gaylord first refers to 
the endemic occurrence of cancer of the thyroid in brook 
trout hatcheries in Germany, recorded by Pick. Pick states 
that his investigations show that certain hatcheries are 
entirely free from this affection and that where the fish are 
affected the disease is confined to individual tanks or pools 
in which the fish are kept; that wild fish introduced into 
those ponds to replenish the stock acquire the disease, and 
this, to his mind, eliminates heredity as a factor in the 
development of the disease. The nature of the affection 
is true carcinoma, and he concludes that this endemic 
occurrence of cancer among trout in certain tanks only 
indicates that the water of these tanks contains the agent 
which is the cause of the disease. Dr. Gaylord tten pro¬ 
ceeds to narrate many instances of cancer occurring in rats 

which developed the disease after occupation of cages pre¬ 
viously occupied by other rats suffering from cancer. These 
instances are quoted by several observers, both medical and 
lay, in the latter case by the man who supplied rats to the 
laboratory for experimental purposes. It was found that 
when the infected cages were thoroughly disinfected no 
further infection occurred. 

Auto-inoculation of Cancer. 

To my mind, the strongest argument which can be adduced 
in favour of the exogenesis of cancer is one of its most dis¬ 
tinguishing characteristics—viz., its undeviatiDg method of 
growth and dissemination by proliferation and metastasis 
and auto-inoculatioD. Although cancer is unquestionably 
purely local at the outset, unfortunately it does not long 
remain so. Indeed, it would be completely under the con¬ 
trol of the surgeon’s knife and would lose all its terrors were 
it not for the fatal metastases which are invariably formed 
and that with a startling rapidity which is not sufficiently 

Mr. C. B. Lockwood 7 has drawn attention to this rapid 
extension of the disease in a communication entitled, 
"Carcinoma of the Breast and its Spread into the 
Lymphatics.” He points out that in malignant growths of 
organs which have no capsule—e.g., the mamma, tongue, or 
pharynx—hardly any interval of time exists between the 
onset cf the disease and its spread into the lymphatics. He 
says, “ In the smallest carcinoma of the breast that I have 
seen the neighbouring lymphatics were already cancerous.” 
It is this inevitable and rapid metastasis which is responsible 
for the equally inevitable failure of the great majority of 
operations for the removal of malignant neoplasms. 

Mr. H. T. Butlin," in his recent address in surgery at the 
annual meeting of the British Medical Association in 1907, on 
"The Contagion of Cancer in Human Beings and Auto¬ 
inoculation,” says : " The key to the problem of communica¬ 
bility of cancer in human beings must surely lie in the study 
of auto-inoculation. If auto-inoculation can be proved on 
such evidence as would be admitted in a court of law there 
is a prima facie case for contagion.” He then goes on to 
say : “ If the proof of auto-inoculation falls through from 
the lack of sufficient evidence it is no longer worth while to 
pursue the study of contagion from individual to individual.” 
Granted, but auto-inoculation of cancer requires no proof. 
Unfortunately for mankind it is indisputable ; it is a marked 
and only too self-evident characteristic feature of the 
malady. Every metastasis is a true auto-inoculation. So, 
also, is every so-called " recurrence.” There is obviously no 
such process as recurrence. That which has been removed 
cannot recur, but what has been left behind continues to 
grow. Worse still, what has been set free from divided 
lymphatics and the tumour itself by tbe surgeon's knife, and 
what that infected knife has itself inoculated in and about 
the wound infallibly grows also. Mr. Bntlln's conception of 
“ auto-inoculation ” appears to be a very limited one, applying 
only to the inoculation of an adjacent healthy surface by an 
affected one. Although it is well known that this auto¬ 
inoculation of adjacent structures not infrequently happens 
its absence or presence is merely of academic interest. Its 
presence is confirmatory, but its absence cannot in tbe 
slightest degree invalidate the obvious fact that auto-inocula¬ 
tion is one of the most marked characteristics of cancer. 
Mr. Butlin's " key ” is therefore ready to his hand, for the 
condition he considers necessary to establish a primd facie 
case for contagion is, only too clearly, already in evidence. 

Mr. But-lin further says : “ Experiment has proved that 
successfully implanted carcinoma invariably presents, both 
in the grait and its metastases, the characters of the car¬ 
cinoma from which it was implanted ”; also that, “no trans¬ 
formation has yet been observed of one variety into another 
variety.” Then, as a corollary to this, he adds, “all cases of 
reputed contagion of cancer, in which the disease is not of 
the same variety, must be unhesitatingly rejected.” With 
regard to his first point, that grafts and their metastases 
always present the same characters as the parent carcinoma, 
it could not possibly be otherwise. It is another character¬ 
istic of cancer that “breeds true,” and every metastasis, 
wherever situated, is an actual fragment, or graft, of the 
original neoplasm, and a cancerous graft implanted success¬ 
fully In another individual Is, to all intents and purposes, a 
metastasis of the tumour supplying the graft. Consequently, 
all implanted carcinoma grafts and their metastases must be 
of the same variety as the original growth. As regards 
the second point, Mr. Butlin must be unaware of the 

S2 Tbh Lancet,] 


[Jan. 11, 1908. 

recent experiments of Ehrlich and Apolant • which have 
demonstrated beyond doubt that even a carcinoma can, 
under given conditions, lead to the development of a sarcoma 
in connective tissue immediately adjacent to it. If, then, a 
carcinoma can give origin to a sarcoma, it is obviously even 
more probable for one variety of carcinoma to originate 
another variety of carcinoma. It does not, therefore, 
appear necessary, after all, to reject the cases of reputed 
contagion in which the disease iB not of the same variety. 
Farther on I shall endeavour to show that any one variety of 
malignant neoplasm may originate any other variety. The 
reason for Mr. Bntlin’s rejection of these cases is entirely 
consistent with his belief, which is that, although he con¬ 
siders cancer to be a parasitic disease, he is not apparently 
able to admit the logical sequitur that a specific parasitic 
disease must be necessarily caused by a specific extrinsic 
parasite. In the Bradshaw lecture 10 delivered by him in 
1905 Mr. Butlin maintains that “cancer is a parasitic 
disease,” but that the “ carcinoma cell ” itself is the parasite 
and ‘ 1 acts as an independent organism like many a 

Is the Cancer Cell Itself tub Parasite? 

Imprimis , there is no such entity as a special “carcinoma 
cell.” Professor D. J. Hamilton" of the University of 
Aberdeen says, with reference to carcinomata: “The old 
notion that there was a special cell indicative of cancer is 
erroneous. The only point which is typical about the cells of 
the tumour is that they are always epithelial ; they have no 
constant morphological features beyond this.” The elements 
of any malignant neoplasm are simply ordinary somatic cells 
which have undergone abnormal, exuberant proliferation 
under a specific stimulus. Transmitted by the lymphatics and 
blood-vessels, or implanted deliberately by artificial means, 
these cells certainly appear to act like independent 
parasites, but they act in this manner not voluntarily but 
only by virtue of the intracellular malignant stimulus which 
is clearly the micro-parasite. 

It is impossible for the “carcinoma cell" to be the true 

Let it be supposed for a moment that the “carcinoma 
cell” could be the parasite, then—1 There must have been 
an original neoplasm for it to come from. How, then, did this 
original growth arise ? Certainly not from any pre-existing 
“carcinoma cell,” since "ex nihilo nihil fit." 2. All 
cases of cancer would also of necessity be due to 
direct contact. 3. All cases of cancer would be of 
only one variety—viz., the same variety as the original 
neoplasm from which the “carcinoma cell" emanated. 
Now, we know that comparatively few cases of cancer are due 
to direct contact ; so few, indeed, that they are not generally 
accepted as genuine, and the “cell parasite ” would account 
for them only. The great majority of malignant neoplasms 
arise apparently spontaneously and sporadically ; also it is 
a characteristic of cancer that its variety is very great. It 
is obvious that the origin of cancer and its great variety must 
be explained in some other way than by the direct implanta¬ 
tion of a “ carcinoma cell ” or by the preposterous sug¬ 
gestion that any somatic cell by any intrinsic stimulus can 
possibly develop de novo a specific disease such as cancer. 
We may as well be asked to believe that tuberculosis, for 
example, can be originated by the agency of an intrinsic 
stimulus. I beg to submit that the living implanted cell 
which may be the starting point of any malignant neoplasm 
must have been derived from a pre-existing neoplasm, and 
that its malignant influence is due to an intracellular micro¬ 
parasite endowed with extraordinary and most malevolent 
powers. It is this intracellular entity which is the “ dais ex 
maohind" or, as it might be more appropriately designated, 
the “ didbolus ex machina" of Mr. Butlin’s “carcinoma-cell 
parasite,” and this micro-parasite can, and does, exist 
independently of any cell. It alone is responsible for the 
original of all neoplasmata. 

With regard to his “carcinoma cell,” Mr. Butlin states 12 
that it exhibits a singular tenacity of life, for such cells have 
been kept for many days at a temperature below 27° F. or 
have been placed in sterilised glass flasks and sent across the 
sea by post and yet have in each case been inoculated with 
as good a result as if they had just been transplanted from 
one individual to another. Later, however, he adds that 
all experiments made with the object of cultivating the 
• * carcinoma cell ” outside the body of the host have resulted 
in failure, and that Ballance and Sbattock have reported that 
they have been unsuccessful even in keeping these cells alive 

outside the host. These statements are contradictory. It is 
impossible for living cells of any kind, malignant or other¬ 
wise, to retain their vitality for any length of time after 
removal from their natural environment. Everyone knows 
that any cells can, by sterilisation, be preserved from de¬ 
composition for an indefinite time, but this preservation is 
not synonymous with vitality. How, then, can these con¬ 
flicting statements be reconciled, and how was it that these 
dislocated “carcinoma cells” were successful in inoculating 
fresh hosts as alleged ? Their success was clearly due to the 
vitality of the intracellular parasite itself and not of the 
encapsuling cells. The vitality of the intracellular parasite 
is of paramount importance for the perpetuation of its 
species and is very great, whereas the vitality of the dis¬ 
located 1 ‘ carcinoma cells ” is of very brief duration and of 
only secondary importance. Although the cell itself is dead 
it can still originate a neoplasm by virtue of the living intra¬ 
cellular parasite, but the resulting neoplasm is, as I shall 
presently show, of a different type from that originated by a 
living cell. 

Classification of Neoplasmata. 

All neoplasms may be divided, clinically, into : (1) benign ; 
and (2) malignant. 

The benign are, for the most part, simply local hyper¬ 
trophies of normal tissue and remain so unless they become 
infected like any other normal tissue, in favourable 
circumstances, and they do not form metastases. These 
benign tumours do not require any specific stimulus to 
originate them, simple stimulus of a mechanical nature 
being quite sufficient in many cases for tbe purpose. They 
are comparable to the pearl of an oyster which is simply the 
deposit of a normal substance around a foreign body. 

Malignant neoplasms are divided into : (1) epitheliomata ; 
and (2) sarcomata. Epitheliomata arise from epithelium, 
originally derived from the epiblast and hypoblast. They 
disseminate themselves chiefly by the lymphatics but also, to 
some extent, by the blood-vesselB. Sarcomata arise from 
connective tissue, originally derived from the mesoblast. 
They, on the other hand, chiefly utilise the blood-vessels for 
propagation but they also utilise the lymphatics. Malignant 
neoplasms cannot arise without the agency of a definite 
specific stimulus. These two great classes are further sub¬ 
divided into very many varieties as regards structure but in 
all other essentials they are practically the samo in each 
case. This great variety is, simply and entirely, due to the 
anatomical diversity of the tissues in which they occur and 
their environment. As Professor Hamilton 11 points out, all 
such subdivisions as osteoid, villous, colloid, chondroid, 
encephaloid, fcc., are " useless and misleading.” 

With regard to their method of origin in the tissues, 
malignant neoplasms are of two distinct types: (I) primary ; 
and (2) secondary. The primary are those formed by the 
proliferation of tbe cells of the local tissue invaded by the 
parasite itself. When the parasite is in a free state or 
encapsuled in a dead cell thrown off from the surface of a 
neoplasm (which practically amounts to the same thing, for 
a cell devoid of vitality is obviously incapable of pro¬ 
liferating and so originating a tumour composed of its own 
elements), and when it gains access to the host, then tbe 
resulting neoplasm will consist of the proliferated elements 
of the local tissue cells invaded. Thus the free parasite 
emanating from a glandular-celled carcinoma may originate 
a squamous-celled carcinoma in another individual if it 
invades such tissue, or the free parasite from a squamous- 
celled carcinoma—of, e.g., the tongue—may give rise to a 
columnar-cell carcinoma of tbe stomach or rectum, or to a 
spheroidal-oelled carcinoma of the mamma, or to any other 
variety of carcinoma, according to the structure of the tissue 
invaded. The great majority of malignant neoplasmB which 
arise, apparently de novo, are of this primary type. They are 
originated directly by the parasite itself and indirectly by the 
tumour from which the parasite is set free. Thus the great 
variety of cancer is accounted for and to the free parasite are 
we indebted for the original neoplasm. 

The secondary are formed of alien cells by the proliferation 
of the directly implanted infective tissue cells themselves, 
acting under the stimulus of intracellular malignant in¬ 
fluence, the micro-parasite. When the parasite is encapsuled 
in a living cell and this cell gains access to any host the 
resulting neoplasm will be of the same variety as the invad¬ 
ing cell, being formed by its proliferation in its new situa¬ 
tion and not by the proliferation of the cells of the local 
tissue invaded, as in the primary type. All that the invaded 

Thb Lancet,] 


[Jan. 11, 1908. 83 

tissue cells do is to provide ordinary nutriment for the pro¬ 
liferating invading cells. Thus, the parasite-bearing living 
cell from, e.g., a columnar-celled carcinoma will originate 
another columnar-celled neoplasm by its own proliferation, 
quite irrespective of the structure or situation of the tissue 
invaded. Such infection is immediate and direct as regards 
the implanted cell and indirect as regards the inclosed 
parasite. All metastatic growths and all auto-inocuiations 
are of this secondary type. For example, the metastasis 
from a neoplasm of the rectum established in the liver or 
lungs consists of proliferated rectal epithelial cells. All 
cases of “ cancer-ii-deux" and all cases of deliberately 
implanted cancerous growths are also of this type. So great 
are the activity and vitality of these malignant parasite¬ 
hearing cells that even one such left behind after an opera¬ 
tion for the removal of a malignant neoplasm is able to 
reproduce it. Thus, the infection of invaded tissues by a 
parasite-bearing living cell, with subsequent proliferation of 
the latter, corresponds to what occurs after an unsuccessful 
operation. Now we see that Mr. Butlin’s “ carcinoma cell ” 
parasite could only originate this secondary type of neoplasm 
while the origin of the enormous majority of malignant new 
growths is left unaccounted for by his hypothesis ; but the 
primary type of origin accounts for this majority and supplies 
the original neoplasm from which the living cell, apparently 
acting as an independent parasite, emanates. It also 
accounts for the great variety of malignant neoplasms, a 
variety only limited by the anatomical diversity of tissues. 

All this demonstrates how true a parasite the micro¬ 
organism responsible for cancer is. In the secondary type 
we find it comfortably ensconced in a living cell which it 
compels to slave for it, when implanted in any situation, 
stimulating it to proliferate and so provide accommodation 
for its numerous progeny. It exerts no personal influence 
whatever on the surrounding local tissue cells, which are 
generous enough to furnish the invaders with food supplies. 
It is only when death of the host occurs, or if perchance a 
cell dies and becomes detached from the colony, that its 
tyranny ceases for a time. Now it must make personal 
exertion and endeavour to find a fresh victim in the cell of 
the nearest available living tissue. Having succeeded in 
gaining a footing it proceeds to induce the selected 
invaded cell to commence work by proliferating, and the 
process progresses as before except that this time it is the 
cells of the local tissue which have both to increase in 
number and find their own food. This is the primary type. 

In all other parasitic diseases the micro-organism of 
causation remains free and active personally, but the cancer 
parasite is the trueit parasite of them all, for it never exists 
free if it can avoid it, but clings to its cell-host with 
indomitable pertinacity. 

The Parasite of Cancer. 

Although its presence is proved by induction, as is also the 
existence of, for example, the micro-parasite of variola, the 
parasitic agent of cancer is, as the Germans say, “ nock nickt 
lionstatirt ” (it has not yet been conclusively demonstrated). 
Doyen of Paris believes that the bacterium known as “ micro¬ 
coccus neoformans ” is the germ responsible for cancer. This 
belief appears to be corroborated by the researches of 
Dr. C. Jacobs and Dr. Victor Geets, the result of which was 
communicated by them to the Royal Belgian Academy of 
Medicine at Brussels in January, 1906. 13 These observers 
report that it is practicable to immunise the human organism 
by means of a series of inoculations of the micrococcus 
neoformans vaccine, provided that these are properly con¬ 
trolled by examination of the opsonic power of the blood. 
They cultivated the micro-organism from 90 per cent, of 
tumours examined and succeeded in producing localised, or 
generalised, neoplasmic lesions in 30 per cent, of the cases, 
by inoculating young and vigorous cultures of the micro¬ 
organism into mice and white rats. They prepare the vaccine 
in exactly the same manner as Koch prepares his tuberculin 
T.R. and treat their patients in a similar way to the vaccine 
treatment of tuberculosis. They allege that in some cases 
they obtain cures, but point out, however, that as tuber¬ 
culin does not cure all cases of tuberculosis, cancer vaccine, 
too, cannot cure all cases of cancer. Success or failure 
depends entirely upon the reserve of vital energy and capacity 
for reaction which each patient possesses, and these differ in 
each case. Other observers—e.g., Wright—have failed to 
confirm these results and they are, I believe, now dis¬ 

Roswal Park, Gaylord, 11 and others in America believe 

that cancer is caused by an organism of the same nature as 
the plasmodiophora brassicic. Their observations seem to 
prove that minute plasmodiophorse are present in carcino¬ 
matous tumours and that they can be grown from such 
tumours through a definite stage in their life cycle. In 
summarising their results and conclusions Dr. W. Ford 
Robertson and Mr. Henry Wade 11 state that they had been 
able to recognise in carcinomatous tumours bodies which, in 
their form and in their reaction to the platinum and silver- 
gold methods, are identical with the plasmodiophora 
brassiest but from th to ,’ 0 th of the size. They had 
succeeded in growing from three carcinomata an organism 
which accurately represented the post-spore or pre-amoeboid 
stage of a plasmodiophora. If plasmodiophora; were present 
in carcinomatous tumours it was hardly open to doubt that 
they had the same relation to the morbid growth as the 
plasmodiophora brassicm had to “club-root,” that was to 
say, that they were the determining etiological factor. 

In a later communication (August, 1907) Dr. Ford 
Robertson 16 claims that he has obtained much new evidence 
which he considers confirmatory of this view, evidence 
derived from cultural and histological observations of the 
occurrence of special intranuclear bodies of the nature of 
those previously described, to show that structures morpho¬ 
logically identical with the spirochteta microgyrata can be 
demonstrated in human carcinomata. Gaylord and Calkins 11 
have also described a special spirochmta in primary and 
transplanted carcinoma of the breast in mice. The con¬ 
firmed discovery that spirochseta pallida is the etiological 
factor in syphilis is analogically suggestive of a spirochaetan 
cause of cancer. Much undoubtedly remains to be done, 
however, before the elusive parasite can be demonstrated to 
the satisfaction of all ; but these discoveries tend to show 
that the net is gradually, but surely, closing around it. 

I offer the suggestion that the examination of fresh, living, 
carcinoma cells on the warm stage of the microscope would 
result in much additional and valuable information ; also 
that the employment of high power microscopy would be a 
great aid to investigation. The objective of a microscope 
reaches the limit of its useful development in the direction 
of increasing magnifying power as soon as, by reason of the 
shortening of the focal length, the diameter of the object 
glass, in its principal plane, is reduced to something not 
much less than the diameter of the pupil. Added power, 
however, to any required extent can be obtained by high power 
oculars, but the image thus obtained is rendered defective 
by the blurring of the image from dust and obstructions in 
and on the lenses, and by the observer’s eyelashes, tears, and 
muscat volitantes ; but, quite recently, the image has been 
rendered perfectly clear and very high magnifying power 
obtained by the skill and ingenuity of an expert in micro¬ 
scopy. In February, 1905, at a meeting of the Royal Institu¬ 
tion of Great Britain, Mr. John W. Gordon 1# described a 
device by which a magnification of 7000 diameters could be 
obtained as well as a perfectly clear field of view. Mr. 
Gordon substitutes for the eyepiece a compound microscope 
with a half-inch objective and an ocular magnifying eight 
times. A ground-glass screen is held in the image plane of 
the principal microscope, and this screen is made to revolve 
and also at the same time to oscillate eccentrically. The 
screen abolishes the intrinsic images of dust and foreign 
matter and the eccentric rotary motion renders the screen 

Quite as important as high magnification of the image is 
good field illumination. Dr. Siedentopf ” has devised a 
system of dark field illumination, applicable to objectives of 
the widest possible aperture, which renders visible objects 
so minute and clustered so close to one another that by no 
other known contrivance can they be rendered separably 
visible at all. I must not further occupy time in describing 
this system of illumination and would refer those interested 
to the Proceedings of the Royal Institution of Great Britain, 
Vol. XVIII. 

There is another desideratum of the greatest importance in 
the histological investigation of cancer which, I fear, is 
more likely to be sought for than found, and that is a specific 
staining reagent which will act on cancerous tissue in an 
analogous manner to the selective action of iodine upon the 
diseased areas in amyloid disease which renders them 
clearly distinct even to the naked eye. It is true that there 
is such a selective stain, but it acts only in oue species of 
malignant neoplasm. I allude to the staining by melanin in 
melanotic cancer. Its presence makes it possible not only 
to detect every particle of original and metastatic growth in 

84 The Lancet,] 


[Jan. 11, 1908. 

this variety, both macroscopically and microscopically, but 
it also permits optical demonstration of the method of dis¬ 
semination by the blood-vessels and lymphatics. This has 
been most ably demonstrated by Mr. W. Sampson Handley 17 
in his Hunterian lecture on the Pathology of Melanotic 
Growths in Relation to their Operative Treatment. 

Tub Condition Precedent. 

Since perfectly healthy tissues are probably immune from, 
or invulnerable to, the attack of the cancer parasite, there 
must be causes predisposing to the acquisition of the disease, 
and these go to form what I have called the “condition 
precedent.” This condition is induced by whatever lowers 
or impairs the power of resistance of the body to infection. 
In the case of cancer the chief factor in producing this 
vulnerability is degeneration of tissue from any cause, but 
more especially that due to obsolescence of organs, senes¬ 
cence, and senility, for cancer is, par excellence , the disease 
of advanced age, though by no means confined to it. This 
is obviously due to the fact that in those of middle and 
advanced age decay is in marked and increasing excess over 
repair (the reverse being the case in youth), and the tissues 
are less equal to the strain of resisting the attack of the 
aggressive parasite, especially when this degeneration exists 
in conjunction with the other predisposing factors of this 
condition, which are chronic disease, continued irritation, 
traumatism, and congenital susceptibility. In my opinion, 
it is the failure to realise the invulnerability of young and 
healthy subjects which is one of the causes of so many un¬ 
successful inoculation experiments. I have discussed this 
point fully in another paper. 2 

Channels and Mode of Infection. 

I have elsewhere 1 * fully considered the channels of 
infection and it remains to consider how one becomes 
exposed, unknowingly, to the risk of attack by the parasite. 
This evil agent appears to be practically omnipresent, as so 
many other pathogenic micro organisms are, such as the 
bacillus tuberculosis, the bacillus tetani, and the malevolent 
legion of micrococci, and it is ever ready to act aggressively 
as opportunity arises and circumstances favour. One hardly 
appreciates how very close the relationship is, if only in¬ 
directly, with our neighbours, including those suffering 
from cancer. All our food, both cooked and uncooked, 
passes through the hands of many individuals, and the only 
safeguard, cleanliuess, on their part is practically beyond 
our control. As evidence of this I give you an instance 
from personal experience. A widespread epidemic of enteric 
fever which occurred in a village near Driffield, in which I 
had several patients, was easily traced to an imported case 
which was nursed by a woman who supplied milk to all those 
attacked. This woman, though altruistic, was a most un¬ 
cleanly person and made it her practice to milk her cows 
without even washing her hands, and that immediately after 
attending to the discharges and soiled linen of her patient. 
Much vegetable food, e.g., salads and fruit, is eaten un¬ 
cooked. Each strawberry, for example, we eat is gathered 
by the unwashed hands of the gatherer. Strawberries also 
lie very near the ground, as do lettuces, &o., and are 
readily accessible to domestic animals, such as the dog and 
cat, which also suffer from external cancer as well as 
from intestinal worms. There is an article published in 
Tiie Lancet of July 16th, 1904, entitled “Fruit and 
Filth,*' 1 '* which will well repay anyone’s perusal, provided 
the reader is nob too greatly under the dominance of his 
nerves, or has not too lively an imagination, for anyone who 
reads that article is not likely to touch strawberries again 
unless he picks them himself from plants above suspicion of 

Far be from me the desire to harrow your feelings too 
deeply, bub how, let me ask, is one to know that the common 
house-fly, which crawls all over our bread and butter, or 
other article of food, was not, immediately before, disporting 
itself on the surface of a cancerous wound ? Flies are well 
known to carry tubercle and typhoid bacilli, as well as other 
pathogenic micro-organisms, on their feet, and in the 
stomach, and it is al-o well known that they have infected 
food and drink with these germs, with disastrous results. I 
would refer you to a very ab’e and suggestive communication 
published in The Lancet of July 27oh, 1907, under the title 
of “The Carriage of Infection by Flies.” 10 This article gives 
the result of experiments made by Dr. R. M. Buchanan, 
bacteriologist to the corporation of Glasgow, with the object 
of demonstrating this fact. I wrote to Dr. Buchanan to 
inquire if he had made any experiments as to the 

cancerous contamination of food by flies and received the 
following reply: “I have not yet tried the experiment yo*» 
suggest with reference to cancer, but hope to do so as soon 
as I can obtain material. The same problem presented itself 
to me in connexion with the death of a friend some years ago 
from intestinal cancer.” 

One’s own footgear must bring much dust, laden with all 
kinds of pathogenic micro-organisms and, on occasion, dust 
from a cancer sufferer’s room, into one’s house, and it 
may easily find its way to one’s food, &c. In this con¬ 
nexion the Eistern custom of leaving the outside shoea 
at the entrance of the house has, truly, much to com¬ 
mend it. Another risk to which we are exposed is 
eating the flesh of animals which have been suffering 
from malignant disease when killed. In December, 1904, 
according to press cuttings in my possession, a man was 
fined £50 and £7 costs at the Guildhall, London, for sending 
meat to Smith field which on examination was fonnd to be 
sarcomatous, lb cannot be assumed thAt this is a solitary 
instance, only it happened to be discovered. Cooking ia 
said to minimise risk, but underdone meat is not unpopular. 

I once knew a dentist who suffered from cancer of the 
prostate, from which he eventually died, and who followed 
his occupation during his illness. One of the physical sign* 
of his malady was a urethral discharge, which necessitated 
frequent manual attention. I have no reason to doubt that 
he occasionally washed his hands! In my own practice 1 a 
patient suffering from a fungating cancer of the mamma 
was nursed by a woman who frequently had occasion to 
remove soiled dressings and who was nob particularly cleanly 
in her habits, and did not always wash her hands before meals. 
Within a year of her patient’s death the nurse developed 
cancer of the stomach and died. This may have been a 
coincidence but I believe it to have been a case of indirect 
infection, a neoplasmic disease of the primary type. 

I have thus indicated a few possibilities ; some may be- 
considered far-fetched, still they are possibilities, and 
unpleasant ones; doubtless many more will occur to your¬ 


From the foregoing it is obvious that the only reliable 
prophylactic against cancer as well as other filth diseases, 
and it is an efficient one, is cleanliness in its widest sense. 
Earth burial, with all its hideous possibilities, should be 
superseded by cremation of all who die from infectious 
disease, and especially from cancer. Cremation would deal 
with the disease at its source. All soiled dressings and dis¬ 
charges from cancerous subjects should be destroyed by fire 
and all rooms inhabited by them should be most thoroughly 
disinfected both during the illness and after death. No food 
should be prepared or consumed with unwashed hands. 

New Facts about Cancer. 

Within recent years several new facts have been discovered 
about cancer. 1. The mitosis of the cells of malignant 
neoplasms has been found to be heterotype in character, 
whereas the mitosis of all somatic cells with one exception, 
and of the cells of benign tumours, is homotype. The 
mitosis of normal reproductive tissue is also heterotype. 
2. It has been discovered that cancer is not restricted to the 
higher vertebrata, e.g., man and the domesticated animals, 
as was at one time supposed, but that it occurs in all 
vertebrata, with the possible exception of certain reptilia. 
The malignant growths occurring in other vertebrata are 
identical with those found in man, clinically, pathologically, 
anatomically, and microscopically. 3. The transmissibility 
of malignant new growths from one lower animal to another 
of the same species has been demonstrated. 

With regard to the first of those discoveries it was the 
resemblance between the mitosis of malignant cells and that 
of normal reproductive tissue cells which led to the 
enunciation 4 by the director of the Imperial Cancer Research 
Fund of the famous analogical fallacy that malignant new 
growths are merely reproductive tissue in abnormal 
situations. The heterotype character of the mitosis of 
malignant cells and the homotype character of somatic and 
benign tumour cells are, indeed, of academic interest but of 
little or no practical importance beyond affording a possible 
means of differential diagnosis in some doubtful cases which, 
however, would signally fail in the case of tumours of the 
reproductive tissues, since the mitosis is heterotype in either 
case, whether benign or malignant. It has been suggested 
to me that the fact of the mitosis of malignant and 
generative tissue cells being heterotype in both cases was 
important as showing that generative tissue cells, like those of 


cancer, have the power of proliferation. Of course, this fact 
cannot prove any such power, since analogy can prove 
nothing, but can merely suggest; still, if it oould prove it 
it would not be necessary to corroborate the power of pro¬ 
liferation of generative cells, since the first infant one comes 
across is ample and convincing proof of that! At the same 
time there is a very suggestive parallel between the two 
proliferations. Neither generative tissue nor other normal 
tissue ceils can proliferate without a specific st imulus. In the 
case of generative tissue the ovum only commences to pro¬ 
liferate when it has been invaded by the spermatozoon, 
which acts practically as an extrinsic specific protozoan 
parasite. The proliferation is enormous and rapid. The 
resulting tumour is benign, though some might consider it to 
be a malignant tumour in a normal situation ! It is easily 
got rid of, and ‘' recurrence ” does not take place unless 
there is reinfection In the case of somatic cells proliferation 
only commences when they are attacked by the cancer 
parasite. Mitosis becomes heterotype, proliferation goes on 
apace, and the tumour is malignant and impossible to 
eradicate. Nothing is known of the method of the influence 
of the cancer parasite on the somatic cell, any more than the 
influence of the spermatozoon on the ovum is understood, but 
it will be admitted that the one process is equally as 
marvellous as the other. 

With regard to the second of these facts, among the verte- 
brata in which cancer has been discovered to exist are certain 
fi-hes, found both in rivers and in the ocean round our coasts. 
This fact has induced the director before mentioned to state" 0 
that “the wide zoological distribution of malignant new 
growths indicates that the cause of cancer is to be sought in a 
disturbance of those phenomena of reproduction and cell-life 
which are common to the forms in which it occurs.” Thus he 
makes another statement of opinion which clearly indicates 
how little is the help towards solution that may be expected 
from intrinsic hypotheses and their advocates. To the 
“man with the open mind,” however, it might probably 
occur, as it certainly does to me, that this wide distribution 
of cancer throughout the vertebrata, with the resulting great 
diversity in environment, food, and conditions of life 
generally, was suggestive of the omnipresence of a specific 
malevolent agent of great vitality ; that, with regard to the 
fluvial and marine fishes found bearing cancerous growths, 
this fact might well suggest that the specific cause of cancer 
is water-borne and, like the bacillus typhosus, it is not 
injuriously affected by sea water ; and, finally, that since 
the neoplasms found in fish are identical in every way with 
those occurring in man, infection may well have arisen 
through the agency of parasite-bearing sewage polluting 
both the rivers and the ocean into which they flow. 

Regarding the third discovery of the trauBmissibility of 
cancer from one individual to another of the same species, 
although this has had to be admitted, it is qualified by the 
assertion that such transmission is merely a transplantation of 
a graft of a malignant tumour and not the genuine inoculation 
of a specific disease. It would be more graceful to concede 
that since transmission between individuals of the same 
species is proved to be possible it may be eventually found 
that transmission between animals of different species, and 
even the development of one variety of malignant growth 
from another, is possible also. 

An admission which may be looked for sooner or later is 
that a carcinoma of epithelial origin has been observed to 
give rise to a sarcoma in the adjacent connective tissue. 
Then will be confirmed the dictum that cancer is a specific 
infective disease and that one specific micro-organism is 
capable of originating every variety of malignant neoplasm, 
the variety depending upon, and only limited by, the 
anatomical diversity of the structure and the situation of the 
tissue invaded. 

Deductive Evidence. 

As it is necessary to apply the striotest canons of logic to 
the arguments brought forward in support of any hypothesis 
I beg to submit the following, which to my mind fulfils this 
postulate. Every specific disease is infectious to the indi¬ 
vidual. By this term, “infectious to the individual,” I 
mean the gradual evolution of disease, more or less rapid, 
locally and constitutionally, over the body from the point of 
origin of the disease. Specific diseases infectious to the 
individual are very numerous and are caused by the agency 
of some extrinsic 'parasite, either a microphyte or a micro- 
zoon. These diseases are communicated to others, directly 
from individual to individual, or indirectly by inanimate 
objects, or through an intermediate host. 

Now cancer is, emphatically, a specific disease, and it is 
intensely infectious to the individual ; therefore, the only 
logical conclusion that can be drawn is that cancer is both 
transmissible to others and that it is caused by an extrinsic 
agent. Except for the solitary fact that the elements of a 
malignant neoplasm—i.e., its cells—are themselves trans¬ 
ported, in addition to the infective agent (which is the 
peculiar and characteristic idiosyncrasy of cancer), this 
disease very closely resembles in its origin and evolution a 
chronic infectious disease. 

My argument may be condensed into two syllogisms— 
viz : 1. All diseases which are infectious to the individual 
are transmissible to others. Cancer is infectious to the 
individual. Therefore cancer is transmissible to others. 
2. All diseases which are infectious to the individual have an 
external origin. Cancer iB infectious to the individual. 
Therefore cancer has an external origin. 

Bibliography. — 1. Brit Med. Jour., July 26th, 1902. 2. Quarterly 
Medical Journal. May. 1905. 3. Practitioner. August, 1907. 4. Brit. 
Med. Jour.. Jan. 30lh. 1904. 5. Antonv and Cleopatra. Act II., Scene ii. 
6. Brit. Med. Jour., Dec. 1st, 1916. 7. Ibid.. Jan. 27th, 19U6. 8. Tat: 

Lancef, August 3rd, 1907. 9. Brit. Med. Jour., Dec. 1st, 19C6. Ehrlich 
uud Apoimit: Centralblatt fur Allgcmtlne Pathologic tins Pathologische 
Auatomie. Band aril.. No. 13, IsCS. Apolaat und Ehrlich : Arbetten 
aus dem Khnlgllchen institut ftir Kxperimcntello Therapie zil Frank¬ 
furt A /M., Heft 1 (Aus der Abtellung iiir Ktebsforschnngl. Ehrlich : 
Experimentelle Studlen an Mauaetumoren, Zritschrlft tttr Krebafor- 
schung, Band v., Ileft 1/2, 1907. 10. The Lancet, Dec. 16ih, 1906. 
11. Hamilton's Text-book of Physiology, vol. i. 12. The Lancet, 
Doc. 16th. 1906. 13. The Lancet. April 7th. 19C6. p. 964. 14. The Lancet, 
August 13th. 1904, p. 469. 16 The Lancet. August 10th. 1997. p. 358. 

16. Proceedings of the Itoyai Institution of Cireat Britain, vol. xviii. 

17. The Lancet, April 6th, 1907, p.927. 18. The Lancet. July 16tb, 
1904, p. 167. 19. The Lancet, July 27th, 1907, p.216. 20, Brit. Med. Jour., 
Jan. 30th, 1204. 




(From the l‘hy*iologioa l Laboratory.) 

The application of FehliDg’s test for the detection of sugar 
in urine is both simple and reliable in the presence of a fair 
amount of sugar. Urines in which a distinct reaction is 
obtained when boiled for a short time with an equal amount 
of Fehling’s solution may, in almost all cases, 1 be held to 
contain excess of sugar, and such urines present bo further 
difficulties. Practical experience, however, as well as an 
examination of the plentiful references to the reaction in 
clinical and other text-bocks, &c., show that the test as 
applied to urine in general Is complicated by many difficulties 
and ambiguities. Different authorities seem to hold very 
divergent views with regard to the exact significance of 
certain results obtained with Fehling’s te6t when the reaction 
is somewhat modified either with regard to the general 
appearance of the precipitate or the time taken to produce 
it. Thus on testing urine it is sometimes found that no 
result is evident after a good deal of heating with Fehling’s 
solution, but that some time after standing an opalescent 
mixture is found to have taken the place of the blue solution, 
or perhaps there is a fairly definite yellowish-green pre¬ 
cipitate. In other cases it is found that the mixture of urine 
and Fehling’s solution gives on boiling for tome time a dirty 
opalescent greenish milky liquid without aDy sign of a 
definite precipitate ; at other times a more yellowish-green 
solution is in evidence ; and all stages from a faint dirty 
greenish opalescence to a definite yellowish mixture exhibit¬ 
ing undoubted evidence of a precipitate may from time to 
time be seen in clinical work. 

The significance of these ambiguous reactions has not been 
thoroughly dealt with in the literature of the subject and at 
present the general tendency is to explain them in a con¬ 
venient, but not very helpful, way by reference to some dis¬ 
turbance by “interfering" substances. How these latter 
substances are supposed to interfere with the test is generally 
not very plainly indicated, bnt the general impression con¬ 
veyed seems to be that they act in virtue of their direct 
reducing action and thus simulate sugar, though giving at 

l Possible complications with glycuronic add, Ac., are not discuaasd 


the same time a result somewhat different from that obtained 
from sugar, insomuch as the reaction is often modified, the 
result being a greenish and greenish yellow mixture, as 
mentioned above. 

Causation of the Anomalous Reactions. 

Some years ago the writer undertook an investigation into 
this subject in order if possible to elicit the causation of 
these ambiguous results and the clinical significance to be 
attached to them. The results of this investigation were 
published in extenso in the Bioohemioal Journal , a but as the 
subject is exceedingly important from the standpoint of 
practical medicine I propose to deal here with the part of 
greatest interest to the clinician. 

If we take a normal urine giving no reaction with Fehling’s 
solution and add to it a trace of sugar it will generally be 
found, on subsequent testing in the usual way, that no 
evidence of the presence of the added sugar can be detected ; 
that this is not due to any lack of delicacy on the part of 
Fehling’s solution is evident from the fact that this reagent 
will readily detect such a small quantity of sugar as 1 part 
in 126,000 parts water (0 0008 per cent.). Now since several 
times this amount of sugar often gives no result when added 
to normal urine and tested as usual we at once arrive at the 
conclusion that normal urine contains something which 
prevents small quantities of sugar giving a reaction with 
Fehling’s solution. According to Dr. F. W. Pavy this 
inhibition of precipitation of cuprous oxide is due to the 
ammonia evolved by the action of the alkali of Fehling’s 
solution on the nitrogenous constituents of the urine holding 
the suboxide in solution. In this way, of course, precipita¬ 
tion might be prevented provided the ammonia were present 
in sufficient abundance, but it will be shown later that the 
quantity of ammonia actually present is much too small to be 
of any account in this respect. 

An examination of all the ordinary constituents of urine 
resulted in disclosing the fact that the substance which 
causes this inhibition of precipitation is kreatinin. Kreatinin 
has the power of holding in solution the reduced suboxide 
and so the mixture gives no evidence, so far as precipitation 
is concerned, of the presence of sugar. Now, since normal 
urine always contains a certain amount of sugar every urine 
would give a reaction with Fehling’s test were it not for the 
kreatinin. The normal sugar of urine, of course, reduces its 
equivalent amount of Fehling’s solution in the ordinary way 
but since the reduced suboxide is held in solution by 
kreatinin we get no evidence of the presence of sugar and 
thus with Fehling’s solution average normal urine gives no 
apparent reaction. It will be seen that this action of 
kreatinin is more beneficial than otherwise, for it prevents 
mistakes being made with urine containing very little sugar 
—sugar of normal amount and only of physiological 
importance. The first effect therefore of kreatinin is to 
prevent a reaction with small amounts of sugar. 

Nature of the Precipitate. 

Kreatinin, however, possesses another very marked pro¬ 
perty—that of materially modifying the nature of the pre¬ 
cipitate when there is a slight excess of sugar present. It 
will be shown later that this characteristic of kreatinin is a 
most marked one and exceedingly important in affording an 
intelligible explanation of the various different-coloured 
solutions and precipitates described above. In a paper pub¬ 
lished in the above-mentioned journal for April, 1907, I 
entered fully into the phenomenon and showed that the 
different-coloured precipitates obtained in urine testing were 
associated with, and dependent on. a difference in the degree 
of granularity of the particles of the precipitates. Thus, in a 
urine giving, after boiliDg for some time, a dirty greenish 
opalescent solution, the modified colour is due to the fact 
that the precipitate of cuprous oxide is present in an 
exceedingly finely divided state ; in the case of a greenish- 
yellow precipitate the particles are still very fine but rather 
coarser than in the last ; with a yellow precipitate they are 
still somewhat larger, and this increase in the size of the 
particles goes on until in a distinct red precipitate the size 
of the individual granules is much more marked. 

It is customary to state that the red precipitate seen in 
testing distinctly diabetic urine is cuprous oxide, whereas the 
yellow precipitate in evidence when urines containing com¬ 
paratively small amounts of sugar (say from 1 to 2 per cent.) 
are tested is cuprous hydrate. The difference in colour, how¬ 
ever, is not dependent on the chemical nature of the precipi¬ 
tate present but on the state of subdivision of the particles, 

2 February, 1906, and April, 1907, 

and it is likely that all urines really give a precipitate of 
cuprous oxide and that the statement to the effect that the 
yellow precipitate is cuprous hydrate is incorrect. The 
lower hydrate of copper, Cu a (OH) u , is such an unstable 
chemical body as immediately to suggest a doubt whether it 
is possible for it to appear in urine testing in the form of a 
permanent precipitate. With regard to this difference of 
colour of the precipitates being associated with the state of 
subdivision of the particles of the cuprous oxide, it is of 
interest to observe that some months after the publication 
of my paper dealing with the above a paper by Dr. Pavy 
appeared in The Lancet 3 in which my general investiga¬ 
tions were repeated. It is satisfactory to note that the above 
authority has quite confirmed my observations concerning 
the relations of colour and state of subdivision. 

A consideration of the above facts enables us to under¬ 
stand the causation of modified results in urine testing. 
When the urine contains just a slight excess of sugar it 
reduces its equivalent amount of Fehling’s solution in the 
ordinary way, but the kreatinin present modifies the nature 
of the precipitate so that it separates out in exceedingly fine 
particles; these fine particles floating in the liquid give a 
dirty, milky, greenish appearance to the liquid. It is thus 
obvious that these ambiguous precipitates are just modifica¬ 
tions of the usual form, and are often (in fact generally) 
indicative of a slight excess of sugar above the amount 
present in normal urine. Of course, it is obvious that the 
presence of a sufficient amount of some other reducing body 
—e.g., glycuronic acid—would act in the same way, but 
observation shows that sugar is really the substance which 
most often gives these modified reactions. Again, it is 
sometimes necessary, in the case of those ambiguous pre¬ 
cipitates, to boil for some time before a result is obtained ; 
this is due to the fact that the kreatinin holds in solution 
the cuprous oxide formed during the initial stages of boiling, 
and it is only after the kreatinin can hold no more in solu¬ 
tion that the modified precipitate separates out. Since a hot 
kreatinin solution is a more effective solvent than a cold one, 
there is a consequent tendency for the precipitate to settle 
out after standing for some time. 

Reaction with Normal Urine. 

Even normal urine, when boiled long enough with 
Fehling’s solution, will give a distinct precipitate, and a 
consideration of what happens here will help us to make 
clear the processes involved in the case of urines with slight 
excess of sugar. With regard to this the following quota¬ 
tion from my paper may be of interest:— 

The chief reducing substances present in all normal urines are uric 
acid, carbohydrate material (of which the larger part seems to be 
dextrose), and kreatinin. Uric acid and sugnr, however, differ greatly 
from kreatinin in regard to the time required to cause reduction. 
Both substances, in the percentage in which they occur in normal 
urine, are capable of effecting reduction almost immediately on the 
boiling point being reached; in the process of reduction they undergo 
destruction. , , f . _ 

Kreatinin, on the other hand, reduces very slowly indeed. When a 
normal urine is boiled with Fehling'a solution, the uric acid and sugar 
present almost Immediately reduce their equivalent amounts of the 
solution; no effect is perceived owing to the fact that the reduced 
suboxide is held in solution by the kreatinin ; after boiling for a very 
short time t he full reducing effect of both uric acid and sugar is com¬ 
pleted. On continued boiling the kreatinin gradually causes further 
reduction, at the same time becoming grad uallv diminished in amount; 
part of it is probably converted into kreatin while part is destroyed. 

Ultimately a uoiiifc is reached, at which the suboxide reduced by the 
sugar and uric acid, added to that reduced by the kreatinin Itself, is no 
longer capable of being held in solution by the amount of kreatinin 
and its derivatives actually present in the'urine at that moment; at 
this point precipitation occurs. 

Thus it will be seen that the reaction obtained from a normal urine 
is very similar in character to that obtained from a urine containing 
more than the normal amount of sugar, the chief difference being that 
the more sugar present the quicker the reaction occurs. 

In the presence of great excess of sugar the effect of kreatinin is of 
course qu*to obscured and of no practical importance. It will be seen 
that the influence of kreatinin on Fehllng’s solution is very marked 
and important, though Bomewhat different from that Ascribed to it in 
the text-books where its action is generally considered in relation to 
its direct reducing power. This direct action occurs but slowly, and is 
therefore very insignificant w hen Fehling's test is used in the ordinary 
way; its direct inhibitory action, however, explains many points which 
are otherwise obscure, and for which no definite explanation has been 

Dr. Parry's Criticisms. 

In The Lancet of August 3rd, 1907, p. 290, Dr. Pavy 
in a paper advocating his own theory of the phenomenon 
takes exception to certain statements published by the 
writer in the Biochemical Journal for February, 1906, under 
the heading “ Observations on Fehling’s Test for Dextrose 
in Urine.” After satisfying myself as the result of prolonged 

a The Lxxcet, July 27th, 1907, p. 223. 


experimental work that the quantity of ammonia evolved 
from the ordinary nitrogenous constituents—i.e., urea, nric 
acid, kreatinin, ice.—was quite incapable of giving rise to 
the reaction, I performed some experiments with a view to 
determine the possible effect of the ammonia always present 
in “loose” combination. By this, of course, was meant 
any ammonia that might be present in the form of salts as 
distinguished from ammonia generated from the nitrogenous 
constituents. All observers agree that a certain quantity of 
ammonia is always present in this form ; in order to get rid 
of this ammonia I boiled the urine for a short time with the 
alkaline part of Fehling's solution. It this way the action 
of any ammonia present in loose chemical combination was 
disposed of. With regard to this point the statement made 
in my paper was as follows : “Were the reaction due to 
ammonia present in loose combination boiling the urine with 
the alkaline part of Fehling's solution for a comparatively 
short time should be sufficient to remove it.” Dr. Pavy, 
however, seems to argue that my meaning was that the total 
ammonia of the urine—both the ammonia present as such and 
the ammonia generated from the nitrogenous constituents— 
would be evolved after boiling for a short time with the alkaline 
part of Fehling's solution. After quoting my statement as 
given above he proceeds as follows : “ Dr. Maclean surmises 
that boiling the urine with the alkaline part of Fehling’s 
solution for a comparatively short time should be sufficient 
to remove the ammonia. If he had ascertained by observa¬ 
tion the effect produced he could not have expressed himself 
as he has done. As a matter of fact it is difficult to get 
away from the evolution of ammonia,” &c. He then goes on 
to say that even if boiled to solidification ammonia is still 
freely evolved on the addition of water. That ammonia 
comes off after boiling urine and caustic alkali for a very 
long time I have often verified. This fact only adds further 
proof to the assertion that the amount given off in any given 
short period must be very small indeed. This ammonia, 
however, is generated from the nitrogenous constituents of 
the urine, and such ammonia could hardly by any play of 
imagination be referred to as ammonia in “ loose combina¬ 
tion." In quoting my statement (given above) Dr. Pavy 
italicises the words “should be sufficient”; if at the same 
time he had italicised the words “ loose combination ” all 
confusion would have been avoided. 

It is, of course, commonly known that sugar is easily 
destroyed by the action of boiling caustic alkali and this 
fact is often taken advantage of in physiological chemistry 
when we wish to destroy the sugar in any substance 
previous to certain processes—quantitative estimations, 
Jcc.—which would be interfered with by the presence 
of sugar. For instance, in Neumann's well-known 
method for estimating phosphorus, when the substance 
to be operated on contains sugar—eg., milk—it is 
first boiled with caustic alkali. This destructive action 
of caustic alkali towards sugar would, of course, destroy the 
sugar normally present in the urine when the latter is boiled 
with an alkali. Therefore after boiling urine with caustic 
alkali for some time in order to remove the loosely combined 
ammonia as described above it is necessary to add a little 
sugar to the boiled urine in order to test its inhibitory 
power when treated with Fehling’s solution, since the sugar 
normally present has been destroyed. When this was done 
it was found that the urine still possessed marked inhibitory 
power, proving, of course, that the loosely combined 
ammonia was not itself the cause of the inhibitory action. 
With regard to this point, my paper reads : “ Urines how¬ 
ever to which small amounts of dextrose have been added 
previously do not give any more indication of the presence 
of sugar after boiling than before.” “ Previously ” of course 
refers to the boiling of the urine with Fehling's solution. 
In other words, urines which have been boiled for some time 
with caustic alkali, and to which a small amount of sugar is 
added after the boiling is completed and previously to 
boiling with Fehling’s solution (to represent the sugar of 
normal urine destroyed by the boiling alkali) do not give any 
more indication of the presence of sugar than if they had not 
been boiled at all. It may be that the above sentence as 
given in the Biochemical Journal , is ambiguous as far 
as the mere wording is concerned, and that it is possible 
to assign to it the interprepation adopted by Dr. Pavy. 
With reference to this point, Dr. Pavy says that I seemed 
“to have overlooked the destructive action exerted by a 
fixed alkali on dextrose. Instead of their being more 
indication of the presence of sugar after boiling with 
the alkaline part of Fehling’s solution as is suggested should 
he the case through the expulsion of ammonia the actual 

effect that occurs is a disappearance of the sugar. It is easy 
for anyone to boil some dextrose-containing urine with the 
alkaline part of Fehling’s solution, then add the copper 
portion and see the effect produced. Even with as much as 
2 per cent, and over of dextrose present and boiling only for 
one minute sufficient destruction occurs to prevent any sign 
of reaction being obtainable, Ac.” It was, of course, to 
make up for the sugar destroyed that I added sugar to the 
boiled urine and while it is admitted that the sentence as it 
stands might possibly be interpreted as Dr. Pavy suggests 
such an interpretation would hardly have been expected from 
such an authority as Dr. Pavy. 

In the same journal (April, 1907) another article was 
published in which I incidentally emphasised the destructive 
action of caustic alkali on sugar not as something not well 
known already but in regard to the very rapid action of the 
boiling alkali on small amounts of sugar. In the course of 
my research work I happened to ascertain that in many cases 
this fact was not generally appreciated and so thought it 
worth while to draw attention to the point, stating at the 
same time that “while it is a well-known fact that boiling 
with hot alkali destroys sugar it would seem that the 
extreme facility with which this is accomplished is hardly 
appreciated.” With regard to the above Dr. Pavy sayB : 
“In this [article] Dr. Maclean shows that he has dis¬ 
covered the facility with which dextrose is destroyed by the 
agency of a fixed alkali and that he has learnt the caution 
that is required to be exercised in experimenting with sugar 
in the presence of an alkali to escape arriving at a fallacious 
conclusion.” It is obviouB from what has been said that the 
foregoing statement is inapplicable. 

Inhibitory Influence of Ammonia. 

In the same journal I gave the following table with 
regard to the inhibitory effect of ammonia on a weak 
dextrose solution :— 



IS® 2 

- S 



5 £ 

S =? £ bt 


<, Ck 


1 drop. 


Immediate precipitate. 

2 drops. 



1 cubic centi- 



metre of & 0 1 per 
cent, dextrose 

6 „ 


Precipitate after a few seconds 



+ v 

8 „ 


1 cubic centi - 



Precipitate after 6-10 seconds 

Fehling's solution 


boiled with— 

12 „ 


Precipitate after 8-12 seconds 



16 ., 


Precipitate after a little time. 

In these experiments the urine was boiled with the alkaline 
part of Fehling’s solution in a test-tube, just as ordinary 
urine is tested, in order to obtain a result as nearly as 
possible in harmony with the effects of the ammonia 
generated when urine is tested in the usual fashion. Dr. 
Pavy performed similar experiments but under materially 
modified conditions—the mixtuies being heated in a boiling 
salt solution and not boiled directly over the flame—and 
makes the statement that “viewed in this way the table 
given by Dr. MacLcan[does not supply a correct representation. 
It is not correct to represent no effect as being producible by 

one to four drops of dilute solution of ammonia. after 

four drops the interval amounted to seven seconds.after 

six drops of the ammonia solution the interval was observed 
to stand at 12 seconds ; after eight drops, 15 ; after 12 drops, 
20 : after 16 drops, 38,” &c. 

Now boiling the mixture rapidly over the flame is a very 
different matter from heating in a boiling salt solution and 
so no comparison can be drawn between the two sets of 
experiments, more especially since the intervals during which 
precipitation is prevented are, comparatively speaking, so 
insignificant when compared with the time taken for the pro¬ 
duction of a precipitate when normal urine is boiled with 
Fehling’s solution. Such a large amount of ammonia solu¬ 
tion as 16 drops is capable of preventing precipitation only 
for 38 seconds, and since urine (which would never contain 
this amount of ammonia per cubic centimetre) does not as a 
rule give a reaction until the boiling is continued for several 
minutes, I think that my table when viewed in comparison 


with what obtains in urine gives a fairly true idea of the 
relative action of ammonia as an inhibitor of precipitation. 
It is certainly not customary when testing urine for sugar in 
the ordinary way to apply heat by means of a boiling salt 
solution, and as my experiments were purposely so conducted 
as to coincide as nearly as possible with the methods adopted 
generally in urine testing it may fairly be claimed that these 
results are representative of the effects produced in urine. 
A urine which with Febling's solution would give a precipitate 
after, say, four minutes' vigorous boiling would require a 
longer period of heating before a similar precipitate would 
be given if the urine were immersed in a boiling salt 
solution; this can be very simply proved by simple com¬ 
parative experiments, using portions of the same sample. 

I think that the above explanations make it clear that 
in Dr. Pavy’s article in The Lancet of August 3rd my 
observations are unfortunately represented in a manner quite 
different from the true meaning assigned to them by me. 

Dr. Pavy refuses to accept the view that kreatinin is the 
chief substance in urine which gives rise to this inhibitory 
effect, and argues that the evolution of ammonia generated by 
the action of caustic alkali of Fehling’s solution on the 

Table III.— 15 Cubic Centimetre* of Urine B oiled _ with' ‘15 
Cubic Centimetrj* of Alkali for Five Minute*. 




Total amount of 
ammonia evolved In 

Average amount per 
cubic centimetre iu 












2 17 



22 1 

1 47 




1 31 





Average of above experiments = 1'49 milligrammes NH 3 per cubic- 
een timet re in live minutes; ami the average of three sets of experiments 
from 18 different urines = 1'514 milligrammes NIL per cubic centi¬ 
metre evolved in tive minutes. 

The above specimens were obtained from different sources 
and give a fair representation of the amount of ammoDia 
evolved in a given time when urine is boiled with the alkaline 

nitrogenous constituents of the urine is sufficient to bold the 
reduced suboxide in solution when the latter is present in 
small amount. AVnile it is common knowledge that ammonia 
has the power of holding cuprous oxide in solution, my 
assertion was that ammonia “is ordinarily evolved in too 
small an amount to markedly interfere with the reaction ”— 
i.e., the precipitation of the cuprous oxide. In order to 
settle the point conclusively, however, I annex some experi¬ 
ments performed with ordinary urine in which a certain 
quantity of the urine was boiled with an equal volume of 
caustic alkali of the same strength as is present in ordinary 
Fehling's solution ; such a mixture, of course, contains the 
same percentage of alkali as urine when mixed with an 
equal volume of Fehling’s solution. The ammonia was 


collected in the ordinary way by means of sulphuric acid, 

and the latter titrated against sodium hydrate solution. 

The total amount of ammonia given off from the urine could 
in this way be easily and accurately determined, and affords 
a direct and simple means of judging of the part played by 
ammonia as an inhibitor of precipitation of cuprous oxide. 
Different amounts of urine were used, and boiling continued 
for different periods, but the following tables deal with 
mixtures boiled for five minutes, as this space of time 
represents roughly the time required to produce a precipitate 
in many normal urines when boiled with Fehling’s solution. 

Table I .—25 Cubic Centimetres of l T rine Boiled with ~5 
Cubic CentimetreI of Caustic Alkali for Five Minutes. 


[ Specific 

Total amount of 
ammonia evolved in 

Average amount per 
cubic centimetre of urine 
in milligrammes. 











24 6 














Tne average of the six experiments gives an ammonia evolution 
equivalent to 1 252 milligrammes .Nil, to each cubic centimetre of 
urine, this amount being evolved iu live minutes' boiling. 

Table II. — 10 Cubic Centimetres of Urine Boiled with 10 
Cubic Centimetres Caustic Alkali for Five Minutes. 


S peci fic 

Total amount of 
ammonia evolved in 

Average amount per 
cubic centimetre in 
















2 01 







18 5 

1 85 

centimetre evolved iu live minutes. 

part of Fehling's solution. Urines, therefore, may be con¬ 
sidered as capable of evolving from 1 • 5 to 2 milligrammes 
of ammonia per cnbic centimetre when boiled for five 
minutes with an equal volume of sodium hydrate containing 
the same percentage of caustic alkali as is commonly present 
in ordinary Fehling’s solution ; in other words, when urine 
is tested for sugar in the ordinary way with Fehling's solu¬ 
tion 2 cubic centimetres of the mixture if boiled for five 
minutes would generate from 15 to 2 milligrammes 
of ammonia in that time. Now since the ammonia 
formed in the boiling liquid must be quickly driven off the 
amount of this substance present in the mixture at any 
given moment must be exceedingly minute. If we assume 
that the ammonia is formed at an average fixed rate per 
second, then the average amouDt generated per second 
in the boiling liquid will be from 0 005 to O'007 
milligramme KH, per cubic centimetre of urine. Now Dr. 
Pavy Btates that with one cubic centimetre of urine mixed 
with one cubic centimetre of Febliog’s solution the addition 
of oue drop of pure (diluted 1 in 10) ammonia (O'880) 
solution just appreciably hinders precipitation ; observation 
proves that if there is any interval it is really exceedingly 
minute. If, therefore, such a comparatively large amount of 
ammonia as one drop which represents about 1'5 milli¬ 
grammes of ammonia has but the very slightest effect it is- 
obvious that the insignificant amount of ammonia evolved in 
urine testing with Fehling's solution has practically no effect 
in acting as an inhibitor of precipitation. 

Again, if for purposes of comparison we assume that all 
the urea present in one cubic centimetre of urine is changed 
into ammonia say in five minutes’ boiling, a simple calcula¬ 
tion gives the total amount of ammonia formed. Average 
urine contains about 22 milligrammes of urea per cubic 
centimetre. The total ammonia evolution of 22 milligrammes 
of urea is 12'4 milligrammes NH 3 . 

34 99 

CON.jHj = 2(NH,) = *- x ~ = 12'4 mgs. NH S . 

(mol. wt. fcO; (mol. wt. 34) cu A 

If we add another 2'6 milligrammes* for the ammonia 
generated from kreatinin and other nitrogenous bodies that 
may be acted upon, as well as for any ammonia present as- 
such in “loose” combination, the total ammonia evolution 
per cubic centimetre of urine would amount to 15'0 milli¬ 
grammes. Now the inhibitory effect of 16 milligrammes 
NH, is exceedingly small. This amount of ammonia corre¬ 
sponds to the amount present in ten drops of a 1 in 10 pure 
ammonium hydrate solution (0 1 880). 

According to Dr. Pavy’s results ten drops of ammonium 
hydrate of above strength added to a mixture consisting of 
one cubic centimetre of Fehling's solution and one cubic 
centimetre of a 0 1 per cent, solution of dextrose would 
prevent the ordinary reaction for about 17 seconds. 5 Since 
Dr. Pavy’s experiment was performed under conditions 
entirely different from those generally adopted in urine 
testing (heat being applied by means of a boiling salt 
solution) the above period of 17 seconds may be taken as 

* This ia of course ft very liberal allowance and does not represent 
the actual relationship between urea nitrogen and other nitrogen 
present; it is merely given for purposes of comparison. 

5 Ur. Favy's actual figures are : 8 drops = 15 seconds delay; 12 drops 
= 20 seconds delay. From this it is obvious that 10 drops would be 
equal to about 17 seconds. 


the maximum time. Here, then, according to Dr. Pavy, the 
total amount of nitrogen that can be evolved from one cubic 
centimetre of urine is capable of inhibiting the usual 
reaction when 0 1 1 per cent, of sugar is mixed with an equal 
volume of Fehling's solution only for about 17 or 18 seconds. 
Now as Dr. Pavy assumes that ordinary urine contains from 
0'3 to 0 • 5 par cent, sugar it is obvious that a reaction with 
urine would not be inhibited for so long a period as with a 
0'1 per cent, dextrose solution (seeing it contains more 
reducing substance). In fact, with a O’ 5 per cent, solution 
we might reasonably expect little or no inhibitory action. 
Experiment Bhows, however, that one cubic centimetre of 
ordinary urine may be boiled with an equal amount of 
Fehling's solution for anything from three to live minutes 
before a reaction is obtained. 

In the above experiments it is assumed for purposes of 
comparison that all the nitrogenous substances of the urine 
generate all their ammonia when boiled for five minutes 
with the caustic alkali. This, of course, is far from true, 
for it is proved by observation—as shown above—that but a 
comparatively small fraction of the total ammonia is evolved 
in this time. The following quotation from Dr. Pavy’s 
paper is of interest in this respect: “The boiling [of the 
mixture boiled with the alkaline part of Fehling's solution] 
may be carried on in any open capsule until solidification 
has begun to take place and then on adding water and trans¬ 
ferring to a test tube renewed boiling will be found to be 
attended with the free evolution of ammonia made manifest 
by moistened litmus paper introduced into the mouth of the 
tube.” Seeing, therefore, that but a portion of the total 
ammonia is generated after boiling for five minutes it follows 
that the total amount present in the urine at any given time 
must be exceedingly insignificant both in quantity and 
inhibitory effect; in fact, it is certain that the ammonia can 
count for little or nothing in preventing precipitation of 
cuprous oxide in urine. 

It might possibly be argued that the addition of ammonia 
as such to a mixture of sugar and Fehling's solution is not 
tantamount to the gradual production of ammonia in urine, 
and that after a few seconds’ heating the ammonia is driven 
off. This objection is not a valid one. for the usual tests dis¬ 
close the fact that ammonia when added to a solution of 
sugar boiled with Fehling's solution comes off in considerable 
abundance after the cuprous oxide has been precipitated ; in 
fact, it is obviously much more abundant after the addition 
of a drop or two of the above dilute solution, them it is in the 
case of urine where, though ammonia is continuously evolved 
during the process of boiling, the indications of its presence 
given by prepared test papers held over the boiling liquid 
suggest that it is present in comparatively small amount at 
any given time. Again, as above mentioned, an amount of 
ammonia amounting to about 1 • 5 milligrammes when added 
to one cubic centimetre of 0’1 per cent, dextrose with 
one cubio centimetre of Fehling’s solution and boiled, has 
but a very insignificant, if any, action as an inhibitor of pre¬ 
cipitation, and here the precipitate occurs before the 
ammonia could possibly be boiled off ; this is a case in 
which a fair amount of ammonia is present and yet there is 
little or no inhibitory action. 

Influence of Kreatinin in Association Kith Urea. 

Dr. Pavy again quotes from my paper the following 

Urea, in the percentage in whicti it occurs in urine, vioids much 
more ammonia than the kreatinin of an equal amount of urine, and vet 
it possesses no SDparent retarding effects: for s verv dilute solution of 
dextrose ideas than 001 per cent.l introduced into a 2'3 percent, urea 
solution and mixed with equal parts of Fehliug's solution gives quite a 
distinct reaction. 

He then proceeds to say that when kreatinin is associated 
with the ammonia-generatiDg product—urea—an effect is 
producible beyond that which is capable of being 
occasioned by kreatinin alone. Now, it is a fact beyond 
dispute that urea in the maximum percentage in which it 
ever occurs in urine produces no inhibitory reaction in a weak 
(say O'01 per cent.) solution of sugar when the test is 
performed in the usual way. Dr. Pavy, however, finds that 
one cubio centimetre of a 01 per cent, sugar solution 
containing/owv times the urea present in normal urine gives 
a precipitate slightly in arrear of a similar mixture without 
urea and so argues that urea has of itself an inhibiting effect. 
This statement conveys a wrong impression with regard to 
the real facts, for Dr. Pavy admits that urea in the percentage 
in which it occurs in urine, produces no inhibitory effect when 
boiled with sugar and Fehling’s solution, and it was urine— 

or mixtures equivalent in strength of urea to urine—that I 
had under consideration when I published the above. The 
statement that fonr times tbe amount of urea present in urine 
has a slight effect in inhibiting the reaction is practically 
irrelevant, seeing that urine never varies in its urea content 
to snch an extent as this. The urea of urine, therefore, 
though generating much more ammonia than kreatinin, hss 
no effect in preventing precipitation. 

Again, it is argued by Dr. Pavy that urea greatly enhances 
the inhibiting effect of kreatinin in virtue of the 
ammonia given off. Tbe statement is made that with 0 05 
milligramme of kreatinin 4- 1 cubic centimetre of Fehling’s 
solution +- 1 cubic centimetre of 01 per cent, sugar solution, 
the latter being mixed with two drops of 40 per cent, solution 
(i.e., twice the amount of urea for an equivalent amount of 
nrine), inhibition was delayed for 35 seconds. Now, if this 
inhibition was caused by ammonia it is obvious that a very 
small amount of ammonia must be capable of increasing tbe 
inhibitory effect of kreatinin. Shortly after the above, how¬ 
ever, Dr. Pavy makes the statement that with one or two 
drops of a 1 in 10 solution of strong ammonia there is no 
effect produced in inhibiting the reaction of the kreatinin 
when one cubic centimetre of a 0'1 per cent, solution of 
dextrose, one cubic centimetre of Fehling's solution, and one 
milligramme of kreatinin are heated. Now two drops of the 
above ammonia solution are equivalent to about three milli¬ 
grammes of ammonia, and since experiment proves that urea 
does not give up more than about one-fifth or one-sixth or so 
of its nitrogen when boiled for five minutes it is obvions that 
the amount of ammonia generated in 35 seconds must be 
very small ; the total possible evolution (assuming that all 
the N. of the urea is changed) is only 24 ’8 milligrammes 
of ammonia, and taking one-sixth of that amount we get 4 ’2 
milligrammes of ammonia for five minutes’ boiling. We are 
therefore justified in assuming that not more than three 
milligrammes of ammonia are generated in 35 seconds' boiling, 
and this amount of ammonia, according to Dr. Pavy’s second 
statement, produces no effect in augmenting the inhibitory 
power of kreatinin. Even the untenable assumption that ail 
the urea is changed in 35 seconds may be examined with 
profit; here 24 • 8 milligrammes of ammonia would be 
generated—an amount corresponding to about 16 drops of 
above ammonia solution, and we have it on Dr. Pavy's 
authority that 15 drops produce no effect. If, on the other 
hand, we assume that a good deal more than thiee 
milligrammes of ammonia is evolved, then, according 
to the same authority, this amount of ammonia should 
decrease instead of increase tbe inhibiting effect of 
kreatinin, for it is stated that over three milligrammes 
up to about 15 milligrammes of ammonia added (in solution of 
corresponding strength) to one cubic centimetre of a 0 • 1 per 
cent, sugar solution containing one milligramme kreatinin 
and heated with an equal amount of Fehling’s solution 
actually decreases the kreatinin inhibitory power. It is only 
after 15 milligrammes are added that an increased effect is 
noticed, and of course it is impossible to imagine that any¬ 
thing beyond 15 milligrammes NH 3 could be evolved from 
the urea in 35 seconds. 

Thus the statement by Dr. Pavy that urea increases the 
inhibitory effects of kreatinin in virtue of the ammonia 
generated is, according to his own observations, incapable 
of being accepted. Much more could be said with regard 
to the above, but it is the experience of the writer that urea 
in the percentage in which it occurs in urine neither 
inhibits the production of a precipitate in a weak sugar 
solution nor adds to any material extent to the inhibitory 
power of the kreatinin. Intervals of a few seconds are of 
no importance, and emphasising the importance of such 
short intervals tends only to produce an erroneous impression 
with regard to what actually happens in normal urine, where 
the time of boiling with Fehling’s solution necessary for the 
production of a precipitate usually extends to minutes 
instead of seconds. 

F.ffi ctiveness of Kreatinin. 

Dr. Pavy bases his objections to my statement that 
kreatinin is the substance responsible for the reaction on the 
argument that the amonnt of kreatinin present in urine is too 
small to be answerable to any material extent as an inhibitor 
of precipitation. Now, according to very exact determina¬ 
tions of the amount of kreatinin in urine made by Folin. 8 
it is estimated that the amount for average urin9 is from 

5 Zeltachrift fiir Physlologische Chemle, Band xli, S. 225. 


1'5 to 2 milligrammes per cubic centimetre. The following 
table taken from his paper is of interest:— 


Amount of 
kreatinin in 
per 10 cubic 
of urine. 

Amount of 
milligram met 
per cubic 


Amount of 
kreatinin in 
per 10 cubic 
of urine. 

Amount of 
kreatinin in 

per cubic 



0 -6). 






1 25 




3 I 




16 6 


4 i 





i 1-31 



2 025 


1 19 8 


Now one cubic centimetre of a 01 per cent, dextrose 
solution when mixed with one cubic centimetre of Fehling's 
solution is on boiling prevented from giving the usual 
precipitate of cuprous oxide for a considerable time by the 
addition of such a relatively small amount of kreatinin as 
one milligramme. Now, since normal urine generally con¬ 
tains, according to the above authority, from 15 to 2 
milligrammes of kreatinin per cubic centimetre, it is obvious 
that urine, if it contains about 0 • 1 per cent, dextrose, would 
be prevented from giving a reaction for a considerable 
time by the amount of kreatinin normally present. Now 
average urine may be said to contain generally about 0 • 1 per 
cent, sugar, or at any rate to have an average reducing 
action due to carbohydrates equivalent to that exerted by a 
0 • 1 per cent, solution of pure dextrose. This can be shown 
by various reagents which are not acted upon by the so-called 
“interfering” substances of urine. Such reagents are 
safranin and sodium-nitro-phenyl-propiolate. With safranin 
as an indicator the following examples of the results 
obtained by the writer may be cited :— 


Specific 1 

Percentage of 
sugar calcu¬ 
lated as 




Percentage of 
sugar calcu¬ 
lated as 

1 1 



6 ! 



2 I 



7 1 






8 1 












10 | 



Here, then, it is seen that the average amount of sugar cor¬ 
responds roughly to about O'09 to O'11 per cent. The 
examination of several hundred normal urines gave on an 
average a reducing power equivalent to 0 • 08 to 0 • 1 per cent, 
glucose—due to urinary carbohydrate. 

The statements made by some observers that average urine 
contains anything up 0 3 per cent, or bo of sugar are not 
borne out by observation, for if this were the case such 
an amount of sugar could be easily detected by Fischer's 
phenyl-hydrazin test. Normal urine does not, as a rule, give 
anything corresponding to a typical reaction with the test; 
this fact and various other tests show that sugar is seldom 
present in an average urine to this extent. That a urine 
may contain occasionally 0 • 2 or 0 ■ 3 per cent, of sugar and 
still be obtained from a healthy or “ normal ” subject is 
quite a different matter, but it is certain that average 
normal urine does not contain in general more than about 
0 • 1 per cent, of sugar. Thus it is seen that the amount of 
kreatinin present is quite sufficient to act in a very effective 
manner as a retarder of cuprous-oxide precipitation when 
minute amounts of sugar are in question. Dr. Pavy, how¬ 
ever, reasons as follows: “Kreatinin dealing with the 
quantity existing in healthy urine has but a limited power in 
delaying suboxide precipitation, and the power is only made 
manifest when the amount of suboxide being dealt with is 
exceedingly small. In the case of one cubic centimetre of a 
1 per 1000 solution of sugar, one cubic centimetre of 
adjusted Fehling’s solution, and one milligramme of 
kreatinin, compared with the counterpart without the 
kreatinin, marked delay is seen to occur. With a large 
quantity of suboxide, however, brought into the question, as, 
for instance, when a 5 per 1000 solution of sugar is used 
with the ordinary Fehling’s solution, it may be said that 
practically no material indication of delay is perceptible. 

In urines giving the anomalous reaction it may be considered 
that somewhere about 3, 4, or possibly 6 per 1000 of sugar 
may be reckoned to be present, from which it follows that 
the kreatinin constituent cannot be regarded as answerable 
to any material extent for the delaying effect that may be 
noticed to occur.” 

Now the admission that one milligramme of kreatinin per 
cubic centimetre causes considerable delay is tantamount to 
saying that this amount would cause considerable delay in 
urine. As above stated, the amount in urine is generally 
considerably above this (from 1-5 to 2 milligrammes per 
cubic centimetre), and since the sugar generally corresponds 
to about 0 ■ 1 per cent, it is obvious that the kreatinin present 
is answerable to a very material extent for the delaying 
effect that occurs. The statement that urines giving the 
“ anomalous reaction ” (if this really means, as judged from 
the context, delayed precipitation or, in other words, average 
normal urines) contain about 0 1 3, 0 4, or possibly 0'5 per 
cent, of sugar is. in the opinion of the writer, as the result 
of exhaustive experimental work, absolutely unfounded. It 
has been my constant experience that urines giving a sugar 
equivalent of such a comparatively small amount of sugar as 
about 0'25 per cent, (or even less) invariably gave the usual 
modified reaction with Fehling’s solution after boiling for a 
very short time, and never corresponded in their behaviour in 
this respect with average urine. Dr. Pavy then proceeds to 
argue that an increase in the alkali of Fehling's solution will 
prolong the interval prior to precipitation. With large 
amounts of alkali it is quite possible that some prolongation 
may be in evidence, but at most the difference does not 
amount to very much—at any rate, with moderate amounts 
of alkali—when considered in relation to the time taken by 
normal urine. Moreover, I have considered the reaction 
with ordinary Fehling’s solution in regard to which 
I have already shown that the action of the alkali 
on the urea, Ac., has little or no influence. Again, since 
Dr. Pavy admits that the amount of ammonia generated 
from kreatinin alone is not sufficient to inhibit the reaction 
it is obvious that, in solutions such as the above, in which 
there is no other product present to generate ammonia, the 
action must be brought about by some other means than by 
the evolution of ammonia. Therefore I think it is obvious 
that the above criticisms by Dr. Pavy can hardly be regarded 
as in any degree tending to invalidate my statement that 
“kreatinin is the substance in normal urine which most 
markedly interferes with Fehling’s reaction in the presence of 

small amounts of sugar.kreatinin directly inhibits the 

effect of small amounts of sugar when boiled with F'ehling’s 
solution by holding the reduced suboxide in solution and 
not indirectly by generating ammonia; the latter is not 
present in sufficient quantity to materially affect the re¬ 

Xole. —For the full publications on the subject dealing with the 
points mentioned above see my paper in the Biochemical Journal for 
February, 1906, and April, 1907 ; also Dr. Favy's papers In Tar Lancet- 
of July 27th (p. 223) and August 3rd (p. 290) and 10th (p. 361), 1907. 


By ARTHUR RANSOME, M.D. Cantab., F.R.C.P. Lond., 


Th>: subject of F'erments has been chosen for our con¬ 
sideration this evening because I wish to point out the mode 
of action of organised and unorganised ferments and their 
relationship to one another. It is also not without its bearing 
upon some forms of disease. 

The analogy between fermentations of different kinds and 
the course of various eruptive fevers was indeed early 
recognjfejLby ancient medical writers. Thus Robert Boyle, 
England's grteflf philosopher, writing in the seventeenth 
century, says 3 : “liethat thoroughly understands the nature 
of ferments and fermentations shall probably be much better 
able than he that ignores them to give a fair account of 
several diseases (as well fevers as others) which will perhaps 
never be thoroughly understood, without an insight into the 

1 A paper rend before the Bournemouth Medical Society on Dec. 11th, 
3 Boyle'a Works, Edition 1744, vol. 1., p. 476. 



doctrine of fermentation." He also realised that these fer¬ 
ments came from the outer air, for he says farther: “Those 
parts of the atmosphere which, in a stricter sense, may 
be called the air, are in some parts so intermixed with 
particles of different kinds, that among so great a number 
of various sorts of them, ’tie very likely there should 
be some kind of an uncommon or unobservable nature.” 
Again, a quaint writer, Mr. Place, speaking of the plague, 
sajs 3 : “ When we consider what avast deal of vapours a 
small thing sends ont, and what a large space of air it will 
fill with it, and diffuse itself through, we may conceive a 
city, thoroughly infected, to be as it were clouded in pesti¬ 
lential fumes, as it would be with smoak, if on fire ; and, if 
it come near such representation, ’tis vain to ask what way 
men, living amongst it, receive the infection ; whether they 
draw it in with the breath, or it gets into the stomach by the 
venom sticking to what they eat or drink, or directly climbs 
into the brain by the sensory of the nose, since it is much 
'tis all these ways.” 

In one of the early years of the registration of deaths the 
great master of statistics, Dr. William Karr, 1 crystallised all 
these imaginings into the one word “ zymotic ” as applied to 
various eruptive and other contagious complaints. As he 
said then: “The property of communicating their action, 
and affecting analogous transformations in other bodies, is 
as important, as it is characteristic of these diseases, which 
it is proposed therefore to call, in this sense, ‘ zymotic ’ (from 
(V/iiw: I ferment).” In another passage he says: 3 “The 
diseases of this nature are called Zymotic diseases; the 
peculiar processes, Zymoses: to distinguish them from 
fermentations, with which they have more points of contact 
than they have with combustion, or any common propagated 
chemical action.” 

It is scarcely necessary to point out how completely these 
anticipations of the old writers have been verified. A 
multitude of diseases have now been traced to the presence 
of micro-organisms similar in nature to the ferment of yeast 
and others to protozoa belonging to the animal kingdom. 
Toxins also and antitoxins of a specific character have been 
recognised, stored up, and used as prophylactics and 

There is no need to go into further detail on the important 
facts thus far ascertained, but it may be interesting to 
discuss the nature of the fermentative actions concerned 
and to attempt to point out the several modes in which they 
bring about the physiological and pathological changes of 
which they are the causes. About the middle of the last 
century a fierce controversy raged as to the nature of fermen¬ 
tation. On the one hand, the late Baron Liebig, who may 
be regarded as the father of modern organic chemistry, 
defended a sort of physico-chemical theory which he derived 
from his observation of the unorganised ferments of bitter 
almonds and of mustard seed. On the other hand, Berzelius 
and Dumas regarded fermentative changes as due to the vital 
reactions of living micro-organisms similar to the then 
recently discovered “yeast plant.” Baron Liebig affirmed 
that fermentation was due to the communication of internal 
motion from the particles of a ferment to the particles of 
the fermenting substance, this movement causing an atomic 
change and consequent decomposition. The action was 
supposed to be usually started by oxygen and to be analogous 
to that of heat. 

More than 40 years ago I-ventured to point out that this 
theory is identical with that propounded by Sir Itaac 
Newton about 200 years before. With his marvellous in¬ 
tuition he thus Bpeaks of fermentation in his treatise on 
Upticks ” 11 “The air abounds with acid vapours (oxygen) 
fit to promote fermentation, as appears by the rusting of iron 
and copper in It, the kindling of fire by blowing, and the 
beating of the heart by means of respiration. Now, the 
above-mentioned motions are so great and violent as to show 
that in fermentations the particles of bodies, which almost 
rest, are put Into new motions by a very potent principle 
which acts upon them only when they approach one another, 
(onr molecular force), and causes them to meet and clash 
with great violence, and grow hot with the motion, and dash 
one another into pieces, and vanish into air and vapour and 
ilame.” Pat this into modern terminology and it exactly 
gives Liebig’s theory. Is it not a wonderful instance of 
philosophical insight ? A little later also, Mr. Place, whom 

3 Hypothetical Notion of the Plague, p. 12. 
* Vital Statistics, 1885, p. 246. 

3 P.327. 

• Second edition, 1715, vol. 11., p. 355. 

I have already qnoted, writing in 1721, says : “ Infection is 
a communication of motion by activity”; and again, “All 
contagions operation is of the same quality as that of fire 
and differs from it only in degree." 

As I have said, these views of Baron Liebig were not 
allowed to go unchallenged, and the controversy was not 
always carried on with appropriate scientific calmness. 
Hard things were said on both sides, and Liebig justly 
pointed out that Dumas and others, in invoking vital action, 
as an explanation of the phenomena of fermentation, were 
in no way doing anything to explain it, as they could not 
show how the micro-organisms acted. In an open letter to 
Dumas Liebig made fun of this view and gave a humorous 
account of a supposed experience of his own. He declared 
that as he was one day watching under the microscope the 
cells of the yeast plant he saw them suddenly take on an 
elongated appearance which presently caused them to assume 
the exact shape of miniature champagne bottles, at first 
well corked, but, by-and-by, the corks flew out and the 
stage was soon flooded with excellent sparkling wine. 

Liebig’s own theory was, however, open to several strong 
objections. 1. In the first place, oxygen is certainly not 
essential to the process. 2. The decomposition of the 
ferment does not necessarily take place, though there is 
probably some modification in its nature. 3. On the con¬ 
trary, the preserving power of the gastric juice and the fact 
that many fermentations will go on in the presence of 
powerful antiseptics would lead us to the conclusion that 
the decomposition of the ferment is certainly not essential. 
4. When ferments putrefy they lose their power. 5. The 
action of most ferments is specific ; each ferment will only 
act upon its appropriate material. 6. The result, in many 
cases, is not decomposition or lysis, but synthesis. 7. Lastly, 
in many instances the presence of living organisms is 
necessary to the action. 

Fermentations may, indeed, be grouped under two heads : 
first, those in which micro-organisms are always present ; and 
secondly, those in which the specific agent is unorganised. 
The Germans call them “formte” and “ungeformte 
Fermente,” respectively. In the first group are included : 
(I) all the organisms concerned in the production of 
fermented liquors ; (2) the micro-organisms producing 
various eruptive, contagious, and non-contagious diseases, 
such as scarlet fever, measles, and the like, whooping-cough, 
diphtheria, ague, sleeping sickness; and, lastly, the various 
epizootics. In the second group are : (1) all the physiological 
ferments ; (2) those bringing together the components of 
essential oils and of dyes ; (3) those which assist in the 
ripening of fruits; and (4) the unorganised derivatives of 
living ferments. At first sight these two groups of ferments 
would seem to be quite distinct not only in their form but 
also in their mode of action. Yet it may be that this is not 
the case. 

In truth, little is known as yet as to the exact nature of 
fermentative action. It is certainly not due simply to 
chemical affinity, though it affects the chemical affinities of 
other substances. A true ferment, such as diastase, will 
change successive portions of the substance, starch, upon 
which it has a specific action ; and its power is only slightly 
lessened after each fresh admixture. Moreover, it never 
enters into chemical combination with the object of its 
attacks. Its closest analogues are rather such inorganic 
bodies as spongy platinum and animal charcoal, which owe 
their power to surface condensation, and are hence called 
“catalytes" or “catalysts.” These bodies, by their very 
inability to enter into chemical combination, permit their 
surfaces when cleansed by heat, or in other ways, to come 
into such close contact with gases or liquids as to enable 
what are called molecular forces to come into play. 

It appears, then, that we have to attempt to explain 
fermentative action, of which we know little, by means of 
molecular force, of which we probably know less. It will be 
well, however, to recall what is known about it. We may 
with safety affirm the following propositions with regard to 
molecular influence : I. That molecular influence depends 
essentially upon the elementary molecular constitution of 
bodies. 2. That it acts without regard to mass. 3. That it 
increases inversely as the distance, at some enormous ratio, 
being excessively powerful within molecular distances, and 
utterly insensible beyond them. 4. That its action is in 
some way affected by calorific, electric, and probably by 
luminous vibrations and by chemical affinity. 5. That it 
does not seem to differ in kind from the attraction of cohesion, 
which binds together the molecules of tlje same substance 


6. That chemical affinity may be similar in kind, but that it 
differs from molecular attraction in the power of producing 
chemical combination of the molecules between which it acts. 

When molecular operations take place between the particles 
of bodies of dissimilar composition the following conditions 
are found to favour the production of molecular changes : 
1. That two or more of the substances submitted to molecular 
influences should have a more or less powerful attraction for 
one another. 2. That their physical condition be favourable 
to molecular action. 3. That the molecular agent or 
“ catalyte ” should have very low chemical affinities for the 
substances acted upon. 4. That the molecules of the 
catalyte be free—i.e., that their surfaces be clear of any 
contamination by other liquids or gases. 6. That the 
catalyte be freely permeable by other substances. All these 
conditions are fulfilled by typical catalytes such as “ platinum 
black and animal charcoal.” 

In his work on Electrons Sir Oliver Lodge 7 attempts to 
account for some of the phenomena of molecular action. 
Thus (p. 155) he says: “There is another kind of adhesion 
or cohesion of molecules, not chemical, but what is called 
molecular. This occurs between atoms not possessing ionic 
or extra charges, but each quite neutral, consisting of paired- 
off groups of electrons. At any moderate distance the force 
of attraction between paired electrons will be next to 
nothing, but at very minute distances it may be very great, 
ultimately becoming almost indistingnishable from chemical 
combination, except that the cling will be a weak cling at a 
multitude of points, instead of an intense cling at only one.” 
He gives diagrams illustrating his theory and then continues: 
“Molecular forces on this view are electrical, just us much 
electrical as are chemical forces; but they occur between 
chemically saturated molecules and are due to the interaction 
or distant influence of paired electrons on each other across 
molecular distances. It may be said to be a result of 
residual affinity.” 

There are probably other conditions governing the 
molecular action of “catalytes,” whether inorganic, organic, 
or organised, but on further examination they may perhaps 
suffice to show the intimate relationship that exists between 
all kinds of ferments. Let us take first the action of our 
Becond group, the “unformed” ferments, such as diastase, 
pepsin, trypsin, erythrozyme, synaptase, and the like; and the 
various products of organised forms, such as are secreted by 
yeast, and by divers other micro organisms. 1. These bodies 
all possess the characters which, as we have seen, belong to 
“catalytes.” They are all nitrogenous substances and thus 
contain one of the most chemically inert bodies in nature. 
These compounds are also among the most unstable bodies 
in nature—eg., nitroglycerine, kc. 2. They are all 
“colloidal” in structure and are thus themselves chemically 
inert. 3. Owing to this structure they are bodies in a state 
of continual molecular change, and their particles are 
constantly being presented to substances in their immediate 
neighbourhood in a fresh, clean, and nascent condition. 
They are thus able to exert to the uttermost any molecular 
power which they may possess. 4. They are all specific in 
their action ; in other words, they only affect substances 
with which they have special molecular affinities. 5. They 
readily permit the diffusion among their particles of other 
bodies, especially those of a crystalloidal character. 

Let us consider for a moment this physical power of 
colloids. Though chemically inert, in the ordinary sense, 
colloids possess a compensating activity of their own, arising 
out of their physical properties. Thus, notwithstanding 
their apparently feeble affinity for water, anhydrous colloids 
can decompose certain crystalloid hydratics, such as hydrated 
alcohol. Further instances of their physical power are to be 
seen in their adhesiveness and in the phenomena of cementa¬ 
tion. The adhesion of colloid to colloid appears to be more 
powerful than that of colloid to crystalloid ; thus, two pieces 
of plate glass left in contact will after a time adhere so 
closely that no division can be detected between them and 
they may be cut and ground without separating ; and, again, 
the intense symoresis of isinglass, dried in a glass vessel 
over sulphuric acid, in vacuo, enables the contracting gelatin 
to tear up the surface of the glass. Colloids also, like 
platinum black and animal charcoal, are extremely per¬ 
meable, and the diffusion of a crystalloid appears to take 
place through a firm jelly with little or no abatement of 

All ferments then are easily penetrated by the material 
upon which they act. Their molecules are loosely aggregated 

7 See Lodge in Nature, 1904, vol. lxx„ p. 176. 

together, thus presenting a large surface and a series of 
points of force from each of which any peculiar molecular 
influence (whatever it may be) can act without perturbation 
from other surrounding molecules. They are all, agaiD, like 
their inorganic congeners, chemically indifferent. This 
character, in fact, is essential to substances acting by 
contact. Although so little is known of molecular forces it 
is certain, as I have before said, that they require extreme 
approximation of the particles influencing each other and 
that their power increases, in some enormous ratio, inversely 
as the distance. It may easily be conceived, therefore, that 
this chemical indifference of ferments will enable their 
ultimate particles to come into close contact with other 
substances without uniting chemically with them and in 
consequence destroying the molecular power of the ferments. 
Chemical inertness is characteristic of the whole range of 
bodies exercising fermentative power. Furthermore, as 
platinum black and its congeners act with the greatest energy 
when their surfaces have been freed from all taint of vapour 
or impurity other than that upon which they are about to act, 
so organic ferments are most active when they are in a nascent 
condition, their particles freshly formed, or at least freshly 
arranged and free to attach themselves to the material 
which is appropriate to them. To come down to concrete 
examples, 1 venture to think, for instance, that the changes 
produced during digestion by the unorganised ferments are 
brought about chiefly by purely molecular influences 
analogous to the so-called catalyses wrought by many 
inorganic substances. On this hypothesis it is not difficult 
to understand why a very small proportion of a ferment 
suffices to act upon large masses of suitable material; for 
the molecular action once completed upon one part of the 
mass is not necessarily exhausted or neutralised thereby. If 
the substanoes formed by the action of the catalyte have less 
molecular affinity for it than the original material had they 
will at once be released ; the original energy of the ferment 
persisting, because the ferment experiences no transforming 
molecular reaction, it will attract fresh portions of the 
more appropriate material, and the action will go on almost 

It has been suggested by more than one observer that the 
action of a ferment is similar in kind to that of NO when it 
acts as a carrier of oxygen to S0 2 in the manufacture of 
sulphuric acid. Others again have in similar fashion 
pointed to the operation of molybdic acid in quickening the 
interaction between peroxide of hydrogen and hydriodic 
acid. In the latter case 13rode has shown that 1 gramme of 
molybdic acid in 31,000,000 litres of water exercises this 
power. This has been compared to the action of a ferment. 
The analogy is, however, not quite sound. Both these 
operations are distinctly chemical in their nature and are 
due to chemical affinities acting in accordance with definite 
atomic weights. Ferments, on the contrary, are chemically 
inert and owe their molecular power to this very fact. In 
other words, in the one case the intermediary effects the 
operation by chemical affinity alone, in the other the 
ferment acts by molecular influence. Notwithstanding this, 
however, it is highly probable that in fermentation there is 
some kind of temporary union between the ferment and the 
body it acts upon, the “substrate” as it is called; but, 
seeing that the ferment is a colloid and chemically inert, it 
is most likely that the nature of the temporary union is 
physical and not chemical. In this account of the process 
it will be evident also that there is no need for a 
chemical change in the product, for the change may be 
a physical one only. The effects wrought, for instance, 
by pepsin upon fibrin, albumin, and other proteins may be a 
molecular one and they are not. without a parallel in the 
history of other colloidal substances. Thus, certain gela¬ 
tinous colloids are liquefied, without chemical change, in 
short spaces of time by very minute quantities of reagents. 
Gelatinous silicic acid is liquefied by very small portions of 
caustic potash. One part of this agent in 10,000 of water 
dissolves 200 parts of silicic acid, estimated as dry, in 60 
minutes at 100° C. The alkali, too, after liquefying the 
colloid may be separated again from it by diffusion into 
water upon a dialyser. This solution, says Dr, Graham, 
who first pointed out the differences between colloids and 
crystalloids, “is analogous to the solution of insoluble 
organic colloids in animal digestion. Liquid silicic acid 
may be represented as the peptone of gelatinous silicic acid. 
Certain other colloids, such as the pure jellies of alumina, 
peroxide of iron, and titanic acid, are even more closely 
assimilated to albumin in this respect, since they are 
peptised by minute quintities of hydrochloric acid.” 


Again, the rapid absorption of albuminons fluids after 
digestion points to Borne change of molecular constitution 
effected by the catalytic action of the fermentB, making the 
peptones, if not crystalloid in their character, at any rate 
diffusive and able to traverse membranous septa. There 
would be nothing contrary to experience even in the first 
supposition. Dr. Graham has shown that colloids are 
capable of taking on the crystalloid form. Thus in the 
11 blood crystals of Funke ” a soft and gelatinous body is seen 
to assume the crystalloid form. The solid condition of water 
also, as in ice and snow, is both colloid and crystalloid ; and 
Quartz declares the same power to be possessed by silica.* 
But it is probable that a mere change of molecular constitu¬ 
tion short of crystallisation may confer the power of diffusion 
upon colloids, seeing that albuminose, produced by the action 
of pepsin on proteids, is endosmotic in character—that is, 
that the digested albumin is so far altered as to make it less 
adhesive to animal membranes and more easily miscible with 
blood and lymph than undigested albumin, and thus capable 
of osmosis. 

Turning now to the first group of ferments, those that are 
formed and living, it is quite possible that even in fermenta¬ 
tions brought about by these organisms the eminently 
catalytic powers of nascent nitrogenous colloids may come 
into play. In his early researches on these fermentations M. 
Pasteur himself concluded that the mycodermic plant which 
effects the change of alcohol into vinegar or into carbonic acid 
and water “does not act by means of some agent which it 
secretes and then leaves to work by itself, but," as he goes on 
to remark, “the chemical phenomena which accompany the 
life of the plant depend upon some peculiar physical condition 
analogous to platinum black." “ It is, however,” he says, 
“ essential to remark that this physical condition of the 
plant is in some way closely bound up with its life.” What¬ 
ever be the mode of their operation, it is certain that the 
organised ferments and probably most of the bacteria are 
able to produce what are called “enzymes,” amorphous 
colloidal substances, which have perfectly specific powers of 
attracting and changing the constitution of certain other 
bodies. Enzymes are, in fact, the organic, but merely 
molecular, catalytes met with in the living cell, and one of 
the earliest of these to be made known was “invertase,” 
extracted by Berthelot from yeast. The “ clastic ” power of 
all these enzymes, probably owing to their colloidal nature, 
is destroyed by temperatures of from 50° to 70° C. (which 
cause coagulation, or, at any rate, a disappearance of the 
interspaces between their molecules), but for the most part 
their activities are not prevented by the presence of anti¬ 
septics. Thus, salicylic acid and thymol in moderate 
quantities do not hinder peptic or tryptic digestions, 
although they prevent the putrefactive changes due to 
organised ferments. 

The enzymes produced by living organisms have been 
grouped under the following heads: (I) proteolytic; 
(2) diastatic; (3) inverting ; (4) coagulation ; and (5) sugar- 
splitting. Among the first group are some, allied to trypsin, 
which act only in alkaline fluids, and others, allied to pepsin, 
which are active under acid reactions. Many bacteria belong 
to the diastatic class and secrete starch-changing enzymes. 
A smaller number of them produce inverting enzymes, con¬ 
verting saccharose into dextrose, others coagulating enzymes. 
Group (5), the sugar-splitting ferments, are, however,"often 
secreted by bacteria and they all seem to be of a similar 
nature to the zymase of yeast cells. In addition to these 
comparatively innocent products bacteria give rise, as we 
well know, to numerous toxins, as well as to ptomaines. 
Many of the former bodies are probably fermentative in 
character, but the latter are crystallisable substances, 
analogous to vegetable alkaloids and compound ammonias. 
This will suffice for the first group. 

Returning now to the subject of ferments in general we 

“ In the last odition of his work on "Human Physiology " Professor 
Starling gives several instances of the crystallisation of proteins. Thus 
he says (p. 31): "It, has long been known that proteins occur in the 
crystalline form in the seeds of certain plants, as in berap-seeds, para- 
nut, and pumpkin, and castor-oil seeds. These crystals, which are 
known as aleuron grains, consist of proteins belonging to the class of 
globulins. By mechanical means they can be separated from the 
surrounding tissues, and after washing be dissolved in a solution of 
magnesia. It is also easy to crystallise egg-albumin and serum- 
albumin. white of egg is treated with an equal bulk of saturated 
solution of ammonium sulphate to precipitate the globulins and 
filtered. The filtrate is rendered slightly acid with dilute acetic acid 
which is added until a Blight precipitate Is formed. The mixture is 
put aside for 24 hours, at t lie end of which time the greater portion of 
the albumin has been precipitated as fine needle-shaped crystals. A 
similar method is used in the case of scrum albumin." 

remark that one of their most important attributes is their 
“specificity ” ; that is, their selection of the substances upon 
which they exert their molecular power ; that, however, this 
selection is not altogether exclusive may be seen from 
the following examples. Thus starch is transformed into 
dextrine and glucose by diastases, by ptyalin, and by many 
other animal substances, but not by pepsin, but the isomeric 
substance inulin is nnaltered by diastase. Cellulose, again, 
is fermented by a peculiar ferment which does not act upon 
starch. Gum and vegetable mncilage are Dot altered by 
saliva or by gastric juice, and assamar, the bitter substance 
formed by toasting bread, sugar, kc., is not fermentable 
at all. Cane sugar is not altered by diastase or by emnlsin, 
but the sugar cane contains a colloid body which converts 
sugar into a substance intermediate between starch and 
glutin. Sorbite, another form of sugar, secreted by the 
mountain ash, is not fermentable by yeast, but when 
left in contact with cheese and chalk it suffers decomposi¬ 
tion, giving rise to lactic acid, alcohol, and butyric 
acid, without previous formation of fermentable sugar. 
Mannite and dulcite are also not fermented by contact with 
yeast, but they are decomposed by lactous ferment 
in presence of chalk, with evolution of CO, and 11 3 0 
and formation of alcohol, lactic acid, and butyric acid. 
Black mustard flour or myronic acid produces the essential 
oil of mustard and glucose under the influence of myrosine, 
but it is unaffected by yeast. Amygdaline is changed by 
emnlsin obtained from a limited number of sources into 
bitter almond oil, prussic acid, and sugar ; but the albumins 
of other plants, rennet, pancreatic juice, and saliva produce 
in it no change. Tannic acid is converted by the pectase of 
gall-nuts or of turnips into gallic acid ; but emnlsin, yeast, 
vegetable or animal albumins and legumin retard rather than 
promote this fermentation. None of the ordinary ferments, 
with the exception of emnlsin, are capable of effecting the 
decomposition of rubian, in madder, but erythro/.yme pro¬ 
duces an effect altogether sui generis. 

The enzymes, derived from living organisms, such as blood 
corpuscles and bacteria, are equally aB specific as, if not 
more specific than, the foregoing ferments. Hsemolysins 
have been found so accurate in their selective power as to 
have been used for the detection of human or other blood¬ 
stains in medico-legal inquiries. Agglutinins and precipitins 
are now widely employed in the diagnosis of microbio 
diseases. Toxins show distinct specific molecular affinities 
for definite structures of the body, as in the case of tetanus 
toxins for the nervous system, and they are daily neutralised 
by appropriate antitoxins. 

From a medical point of view, the last-mentioned subject, 
namely, the action of antitoxins, is the most important of all, 
but it would need another paper in which to discuss it. I 
may say here, however, that I regard the neutralising action 
of an antitoxin upon a toxin as a particular instance of the 
action of a ferment upon its substrate, and I may quote here 
l)r. Abbott’s remark that “for all the foreign irritants from 
which animals have been immunised, be it alien blood, tissue 
cells, milk, or bacteria, there are, circulating normally in the 
blood, ‘complements’ specifically related to each irritant on 
the one hand and to its ' receptor' on the other.” 6 

It is true that Ehrlich believes that the saturation of toxin 
by antitoxin is accomplished by chemical union, but 
Starling 1,1 shows that the amounts of “ agglutinating serum " 
taken up by a suspension of bacilli is not a definite quantity 
but is determined by the concentration of the serum. 
He also points out (p. 38) that “even in a neutralised 
mixture, both free lysin and free antilysiu, or free toxin and 
free antitoxin are present, and it needs only the alteration of 
the physical conditions of the mixture in order to display 
the action of one or other of these bodies.” He asks, “How, 
then, are we to regard this combination of toxin with anti¬ 
toxin 1 ” and he decides that ‘ ‘ though it is impossible to give 
a decisive answer to this question at the present time it 
seems probable that the specific combination of ferments 
with definite substrates is in all respects analogous to the 
combination of toxin or lysin with their corresponding anti¬ 
body.” He further points out that “ the assumption of the 
colloidal condition—a condition in which there is an enormous 
exaggeration of surface—seems to be an important condition 
in deciding the catalytic effect o! any given substance.” He 
instances platinum and other metals in the condition of what 
are called “sols”—i.e., colloidal solution—and he concludes 
that “ in every case we must regard adsorption by a surface 

s Abbott, p. 608. 

10 Physiology of Digestion, p. 37. 


as the essential factor,” though he admits that the exact 
adsorption 11 which takes place is evidently a function of the 
chemical configuration of the substance forming the surface.” 
He goes on : “ We cannot otherwise account for the specific 
interaction between toxins and antitoxins, or for the specific 
action of the different ferments on their various substrates. 
We have here, therefore, a special class of interactions, not 
entirely chemical and not entirely physical, but depending 
for their existence on a cooperation of both chemical and 
physical factors. To definitely assign ferment actions to 
this class would be premature. There is, indeed, evidence 
that ferments act on the substrate by forming intermediate 
combinations with it, but whether these compounds are to be 
regarded as chemical or adsorptive we have not yet sufficient 
evidence to determine. The facts that all the ferments 
belong to the class of imperfect colloids and that in many 
cases—e.g., proteolytic ferments and diastase—their action 
is on complete colloids, would certainly suggest that the 
combinations must be of the physical type.” You will 
observe that this is exactly my own argument and it is no 
small satisfaction to me to find that so eminent a physiologist 
has arrived independently at conclusions which I ventured to 
formulate and to publish more than 40 years ago in a paper 
on the Physiological Relations of Colloid Substances. 11 




By W. B. WARRINGTON, M.D. Lond., F.R.C.P. Lond., 



KEITH W. MONSARRAT, M.B.Edin., F.R.C.S. Edin., 


History of the patient's illness and. remarks thereon by Dr. 
Warrington. —In view of the safety with which the spinal 
cord can now be exposed, a correct diagnosis of the cause of 
paraplegia is of much importance to the patient, for though 
the number of cases in which surgery can intervene is small 
the results obtained when operation is justifiable are 
strikingly successful. The conditions causing a slowly increas¬ 
ing paialysis of the lower limbs are not numerous, and when 
the more common diseases such as disseminated sclerosis, 
amyotrophic lateral sclerosis, syringomyelia, and the results 
of tubercle and syphilis are excluded, and this should not be 
difficult, the diagnosis must be carefully considered, for the 
cause may be one of those conditions in which surgery 
alfords the best or only chance of remedy. Tumours of the 
meninges are naturally the cases in which the most brilliant 
results have been obtained. The essential symptom is the 
combination of pain limited to definite regions of root dis¬ 
tribution with paralysis indicating an advancing transverse 
lesion of the cord. Even should pain be absent, a progressive 
palsy indicating interference with conduction at some level of 
the cord should suggest the presence of a tumour-like growth. 
For in the first place there are a number of cases on record 
in which a tumour has been successfully diagnosed and in 
which pain was not a prominent symptom, and in the second 
place pathology teaches that a simple chronic transverse mye¬ 
litis is a lesion rarely found. Lesions and growths within the 
medulla spinalis itself are considered inoperable. This case 
is recorded as an instance in which a focal intra medullary 
lesion was diagnosed and found and in which the removal of 
about 2 cubic, centimetres of fluid was followed by great 
relative improvement in the patient's condition. The 
pathology of the case is not demonstrable, but the history 
and symptoms lead me to believe that the original lesion was a 
glioma of the cord and its etiology connected with an injury 
A man, aged 22 years, a patient of Dr. E. Cleaton Roberts, 
was first seen by me at the David Lewis Northern Hospital, 

11 Brit. Med. Jour., 1866. 

Liverpool, on Feb. 14tb, 1907. He was completely para¬ 
plegic and gave the following history. In January, 1903, 
when engaged in work in a coal-pit, he slipped on a plate 
at the crossing of truck lines and fell backwards on to one of 
the metals, falling on to the lower part of his spine. He was 
able to continue his work but stated that he at once ex¬ 
perienced pains about his legs. The pain persisted for three 
months, usually of an aching character, but sometimes shoot¬ 
ing down the legs and round the waist. For a short time after 
the accident he had a little difficulty in walking, though 
apparently this did not amount to more than a * ‘ stiffness about 
both hips.” At the end of three months the pains ceased, but 
came on occasionally for the next two years ; he does not 
appear to have suffered in any other way. Loss of power in 
the lower limbs was first noticed in February, 1905 ; it was 
not, however, very marked and under the advice of a dis¬ 
tinguished surgeon he remained completely in bed for three 
months. At the end of this time the patient thinks the 
weakness had increased ; he could, however, just walk about 
with the aid of a stick. Increase in power gradually followed 
and he was able to walk fairly well. At Easter, 1906, 
progress was interrupted by an attack of pneumonia, which 
ran a favourable course, but it is from the period of con¬ 
valescence after his illness that the patient dates the 
onset of his permanent palsy. He was. however, again able 
to walk about without assistance until three months ago 
when on waking in the morning he found that the right 
lower limb was completely powerless. Gradually the power 
of the left diminished and when first seen be was practically 
absolutely paraplegic. Lately the patient had noticed slight 
hesitancy in micturition. 

To summarise this history the salient features appear to 
be ; Injury to the lower part of the Bpine followed by pain in 
the lower limbs and trunk for two years ; a slow and slight 
weakness in the legs becoming worse after a period of rest in 
bed and, after an attack of pneumonia, a gradual recovery, 
then a sudden complete paralysis of the right leg and a 
gradual paralysis of the left, leading to complete paraplegia. 
Nothing of interest was elicited from the family or ante¬ 
cedent medical history. Syphilis could apparently be ex¬ 
cluded and there was no evidence of tuberculosis in any of 
the viscera. 

The condition on examination was as follows. The general 
health of the patient was excellent and no disease other than 
that of the nervous system was detected. The urine was 
normal. Both lower limbs were absolutely powerless with 
the exception of a very feeble flexion of the thighs. The 
limbs were flaccid ; the feet and legs were blue and cold. On 
the inner side of each great toe there was a small sore. The 
muscles were flabby and the right limb in comparison with 
its fellow was wasted. Electrical irritability was normal 
both to faradic and galvanic excitation, though somewhat 
diminished in the right side. Both knee-jerks were ex¬ 
tremely feeble, so that it was doubtful at times if the left 
could be obtained. The ankle-jerks were absent; the right 
plantar response was of a feeble extensor type, the left was not 
obtained. Occasionally involuntary spasmodic flexion move¬ 
ments of the legs and thighs occurred. Abdominal, epi¬ 
gastric, and cremasteric reflexes were not obtained. The 
diaphragm and intercostal muscles acted well. The cranial 
nerves and the upper limbs were normal. The spine was 
carefully examined without detecting any deformity, but 
pressure over the ninth to twelfth dorsal spines caused pain 
round the trnnk at the level of the last rib on both sides. 
Flexion of the spine also caused some pain about the mid 
and lower dorsal region. Retention of urine was present on 
two occasions, once persisting for 86 hours. 

With regard to sensation, a fairly horizontal line starting 
posteriorly from the ninth dorsal spine or passing anteriorly 
through the lowest part of the ensiform cartilage and thus 
corresponding to the seventh dorsal spinal segment formed 
the upper limit of a fairly well-defined loss of sensibility. 
Below this, pain from a pin prick and the recognition of heat 
or cold were absent, but on the right side over the leg and 
thigh a touch by cotton wool was felt as well as the pressure 
produced by the head of a pin. On the left side both these 
forms of sensation also were absent. The patient therefore 
presented the signs of a transverse lesion of the cord at 
about the mid dorsal region, the absolute loss of power, 
great loss of sensation, and the feebleness of the reflexes 
showed that conduction was greatly interfered with, and if 
the disease progressed a complete severance of the brain from 
the lower part of the cord was to be expected. 

In diagnosis, system disease, disseminated sclerosis, and the 


results of acute myelitis or myelomalacia could be excluded. 
There remained to be considered some form of pressure 
paraplegia, syringomyelia, and late effects of trauma. It 
was felt that a study of the history could alone give any 
indication as to the nature of the lesion and it will be 
remembered that sudden paralysis of one limb (the right) 
was a striking feature. Though a sudden paraplegia not 
infrequently occurs in the course of tuberculosis of the 
spine its cause is either an increase in the pressure or a 
softening of the cord itself ; it appeared unlikely that either 
of these conditions would account for a sudden berni- 
paraplegia. On this account, together with the absence of 
local signs in the bones or of constitutional symptoms, caries 
was excluded. New growths and other forms of pressure 
had therefore to be considered. The absence of pain was 
against the diagnosis of extramedullary lesion, though, as 
already mentioned, not conclusively so. The sudden right 
hemiparaplegia indicated a vascular origin as its cause, 
and together with the subsequent slow paralysis of the 
left limb suggested an intramedullary growth and this 
was thought to be a glioma. Gliomatous formations are 
met with in two conditions in the spinal cord—viz., 
(1) the central primary glioma probably a congenital 
lesion and which may remain clinically latent or reacting 
to various conditions, notably traumatism, may evolve and 
produce the characteristic progrestire features of syringo¬ 
myelia ; sind (2) the glioma of the spinal cord, according to 
Schlesinger, the commonest intramedullary tumour. It 
varies greatly in size, it may be small or occupy the 
greater part of the transverse section of the cord. Its 
vertical extent also varies considerably. It is often 
unilateral in position so that the cord looks as if it were the 
site of an extramedullary tumour. The growth may com¬ 
pletely replace the structure of the cord. It is rarely sharply 
defined, is grey-red or grey-brown in colour, and often shows 
cavity formation, thus presenting the greatest resemblance 
to syringomyelia. The vessels of the glioma often degenerate 
and give rise to haemorrhage. 

The hypothesis of haemorrhage into a gliomatous tumour or 
into a cavity in the cord seemed the best explanation of the 
facts of the case and the findings at the operation are con¬ 
sistent with this view. The possibility of haemorrhage into 
a syringeal cavity has been urged by Sir William Gowers on 
clinical evidence. Although the relationship between glioma 
formation and syringomyelia is a very definite one I consider 
this name must be reserved for the special and well-defined 
clinical picture of a progressive disease. So also cavities in 
the cord may arise as the result of several conditions other 
than syringomyelia. 

What was the connexion, if any, between the injury and 
the patient’s illness ! Cavity formation and haemorrhage as 
the results of trauma are well known, hut such lesions as 
the primary effect are not consistent with the long period of 
freedom from palsy and its sodden accentuation nearly four 
years after the injury. On the other hand, that injury may 
be the factor which determines the growth of a glioma in 
the brain is admitted and is probably equally true in the 
case of spinal glioma. It is often maintained that injury is 
only a potent factor if there is a pre-existing excess of glia) 
tissue. This may be, but the importance of the part played 
by injury is not diminished. At the operation a tough 
pellicle was found outside the dura mater evidently of 
inflammatory origin; hence the conclusion is reached that 
the injury was the cause of the patient's symptoms, that the 
pains wore due to bruising of the meninges, and that at the 
same time a gliomatous formation started in the cord ami 
that the growth gave rise to few symptoms until a haemor¬ 
rhage occurred into its substance. 

’The iurgical treatment and findingi at the time of 
operation on May 15th, hy Mr. Monsarrat. —An incision 
was made from the fifth to the tenth dorsal spines. The 
laminte of the sixth to the ninth vertebrae were displayed 
and the four spines clipped through at their bases Bnd 
mobilised. The laminae of the seventh vertebra was sawn 
through, the separation being completed with forceps and 
subsequently the laminae of the sixth, eighth, and ninth 
vertebrae were clipped through with bone scissors. No 
abnormality of the vertebra: was discovered surd no trace of 
previous injury to the bones or to their posterior ligaments. 
The dura mater being exposed, it was seen to be overlaid 
by a tough film of reddish membrane under which a director 
could be inserted. It was raised longitudinally and stripped 
on either side from the underlying dura mater. The dura 
mater was then seen to be abnormally vascular; the 

spinal cord within stowed dark brown in colour.) The 
dura mater was opened but was intimately adherent to 
tho cord and the adhesions bad to be separated by blunt 
dissection. The dura mater was particularly adherent at 
the level of the seventh dorsal vertebra where it was 
markedly thickened by a tough yellow-white fibrous band 
running circularly. There was no escape of cerebro-spinal 
fluid ; the cord bulged through the opened dura mater. On 
inspection the posterior columns appeared transformed into 
a jelly-like substance of a greyish-black colour which pro¬ 
truded more on the right of the middle line. The abnormal 
appearance extended above to the level of the laruma of the 
sixth vertebra and below to within a few lines of the lower 
border of the ninth lamina. A fine knife was inserted in the 
middle line at its lower limit and about two cubic centi¬ 
metres of clear yellow fluid escaped and the protrusion 
collapsed. The knife was again inserted an inch higher 
but only a few drops of blood escaped. No further incisions 
weremade. The dura mater was not sutured. Haemorrhage was 
controlled throughout by pressure and the wound frequently 
irrigated by Bterile saline solution. Four catgut sutures were 
inserted through the spinal muscles on each side and the row 
of spines with their attached ligaments in the middle line. 
A small drain was inserted into the lower part of the wound. 
Throughout the operation, which lasted one and a quarter 
hours, the patient was on his face with the head low. There 
was little shock. 

Reproduction of photograph taken in October, 1907, showing 
the site of 'be scar and the ability of the patient to 
stand with slight support. 

The following abbreviated notes of tie progress of the case 
may be given :— 

May 15th: Comfortable Ihis evening: no pain in back, vomited 
several times, and passed urine involuntarilv. Cathe'cr passed at 
midnight. Patient kept In prone position. Nay i6th : A good deal of 
oozing and discharge of pale-yellow fluid. Catheter used. Patient 
B 3 


turned on to his back. May 17th : Urine passed voluntarily. Blisters 
on inner side of first metatarsophalangeal joint on both feet; these 
were cut and dressed with picric acid. Marked spasmodic jerkiogs of 
flexion of thighs. These are more frequent than before operation. 
May 24th : Wound quite healed. A quantity of serum came away 
from the lower end of incision and firm pads were placed along whole 
length of wound. May 26th: Some movement of toes of right foot 
noticed and can voluntarily invert foot. No movement of left limb. 
The spasmodic jerkings are less than formerly. Sensation roughly 
tested and agrees fairly well with the condition prior to operation but 
pin prick now recognised as such on the right limb. Knee-jerks 
present both sides, right and left. May 28th: Voluntary flexion of 
right thigh. Power in toes greater. Bowels acted naturally for the 
first time. June 1st: Still some collection of serum under the wound, 
horse-hair drain inserted. More power in right limb, and left thigh 
can occasionally be moved. June 6th: Power in both limbs slightly 
greater, the knee- jerks are brisker and an extensor toe response can be 
obtained on both sides. Sores on the toes healing. June 13th : Power 
still improving, spasmodic contraction of muscles marked, especially of 
peroneal muscles. Action of bowel and bladder occasionally involun¬ 
tary. June 15th: Plaster jacket applied from iliac crests to axilla:. 
June 26th : Can stand when supported; walked a few steps with help. 
July 1st: Patient went home. 

Remit of examination on Sept. 26th.— The patient 
has continually improved; he can now, with the help 
of crutches, walk 40 yards without a rest, the limbs being 
slowly advanced, and he states that improvement still 
continues. The right limb is much stronger than the left, 
the leg muscles, quadriceps, and psoas groups acting with 
fair strength. The same muscles act on the left side but 
slightly. He is able to rise from the sitting to the erect 
position. The nutrition of the muscles is good but the feet 
are still blue and cold, there are no sores, and the wound has 
perfectly healed and left a healthy scar. With regard to the 
reflexes both knee-jerks are exaggerated; there is ankle 
clonus on the right side and the ankle-jerk is brisk 
on the left. There is plantar extensor response on 
both Bides. The abdominal, epigastric, and cremasteric re¬ 
sponses are absent. There is no bladder trouble. Aperients 
are required for the bowels and spasmodic movements 
of the limbs readily occur on peripheral stimulation. 
As to sensation, this has altered to this extent, that on the 
right side over the leg and thigh there is but little deficiency. 
A light touch by cotton-wool, a pin prick as sharp, a pin 
head, hot and cold water tubes, and passive movements of 
the joints are fairly well recognised. The localisation of 
touch, “ spot naming,” is inaccurate. On the left side these 
forms of sensibility are very deficient but there is still some 
power of appreciating pressure by the head of a pin from 
that of the point but no pain arises. The upper limit of loss 
of sensation is at the original level and there is now a zone 
on the trunk and outer sides of right thigh corresponding to 
representation of the seventh dorsal to second lumbar 
segment, on which light touch is not recognised nor a prick 
appreciated as such. Thus sensation has greatly improved 
in the right leg and thigh but has diminished in degree over 
an area which corresponds to the extent of the surgical 

Liverpool. _ 


By J. B. NIAS, M.D. Oxon., M.R.C.P. Lond. 

(From the Laboratory of the Inoculation Department , 
St. Mary's Hospital, London.') 

In previous papers which have appeared in The Lancet 1 
it has been shown by Sir Almroth Wright and Dr. W. E. 
Paramore, Dr. G. W. Ross and myself that the carbonates 
and lactates of calcium, magnesium, and strontium are potent 
agents for increasing the coagulability of the blood when 
administered by the mouth to the human subject in doses 
ranging from 30 to 60 grains. It seemed desirable to extend 
this investigation by ascertaining to what extent the same 
property is possessed by the other salts of the alkaline earths 
which are available for pharmaceutical purposes and the 
present paper presents a further instalment of observations 
directed to this end. For liberty to continue this research in 
his laboratory my best thanks are due to Sir Almroth 

The method uniformly followed in this investigation has 

The Lancet, Oct. 14th (p. 1098) and 21st (p. 1164), 1905, and 
August 18th (p. 436), 1906. 

been to administer at a fixed period of the day either to 
myself or others, usually patients suffering from urticaria or 
hemophilia, a definite dose of the drug under trial, and then 
to test the resulting variation in the coagulability of the blood 
during a period of two or more hours. The apparatus used 
consisted of Sir Almroth Wright’s well-known calibrated 
capillary tubes, into which a definite quantity (6 cubic milli¬ 
metres) of blood is sucked, the tube being then immersed in 
water at blood heat, and the contents expelled after a 
measured interval of time on to blotting paper to see if 
coagulation has taken place. In spite of criticisms which 
have appeared as to the sufficiency of this method it has 
proved itself amply adequate for the purpose in hand, very 
consistent results having been obtained. In a paper on the 
subject In the Bioohemioal Journal, vol. 11., part 4, p. 184, 
C. J. Coleman rightly points out that there is a diurnal 
fluctuation in the coagulability of the blood of which note 
must be taken, and that it is particularly affected by the 
taking of food and drink. I have been careful from the 
outset to avoid this source of fallacy by limiting the period 
of observation to the hours from 3 to 7 p.m., the intervening 
time being employed in quiet sedentary work, the same rule 
being observed in the case of patients. The results obtained 
with the different salts available are given below seriatim. 

Magnesium lactate. —This salt is only mentioned to say 
that further experience with it convinces me that it is a 
valuable drug for combating the accidents of bmmophilia 
in cases when as sometimes happens the calcium salts do not 
seem to act. I detailed in a former paper the case of a 
patient of Sir Almroth Wright who being a sufferer from 
haemophilia is liable to periodical oc/.ing of blood from his 
gums. This symptom has been very effectively treated during 
the last 12 months by doses of from 40 to 60 grains once or 
twice repeated either of this lactate or that of strontium. 
The magnesium salt has the advantage for cases of this kind 
in that it can easily be prepared extemporaneously by the 
dispenser by saturating lactio acid with magnesia, which is 
always available. The large dose unfits the compound for 
delivery in a mixture; it should be dissolved in hot water 
by the patient himself. The lactate is a good standard for 
judging other Balts by, a dose of 30 grains generally pro¬ 
ducing a reduction of 30 per cent, in the time of coagulation 
either from 3 minutes to 2, or Irom 2 to 14. 

Boro-oitratc of magnesium. —This is a soluble salt said by 
Martindale and Westcott to have been introduced for the 
purpose of conveying boric acid into the bladder in cases of 
cystitis. Its efficiency in this respect I am unable to state, 
but the drug undoubtedly undergoes some dissociation in the 
body. It is not without effect as a haemostatic, but I should 
class it as inferior to the lactate for this purpose. The 
following are particulars of some trials with this drug, which 
were repeated more than once with similar results. On one 
occasion 30 grains given to the patient before mentioned 
redneed the coagulation time of the blood from 21 minutes 
to 2 minutes and 20 seconds in the course of 2 hours, a 
relatively poor result. On another occasion the same dose 
procured a reduction in the course of 1 hour from 2 1 to 
11 minutes, at which figure the time remained until the con¬ 
clusion of the experiment 1 hour later. Simultaneously the 
same dose was taken by myself after the coagulability of my 
blood had been purposely lowered by the free consumption 
of fruit; a reduction was obtained from Zi minutes to 
2 minutes and 10 seconds in the course of 60 minutes and to 
11 minutes at the end of 20 minutes more, no further reduc¬ 
tion taking place. The boro-citrate of magnesium is, there¬ 
fore, not altogether inefficacious in affecting the blood but 
seems to present no obvious advantage; in this case, also, 
the bulk of the dose requires dispensing in powder form. 

Magnesium carbonate. —Although the doses given by Sir 
Almroth Wright and Dr. Paramore amounted to 60 grains of 
the carbonate the usual medicinal dose of 10 grains contains 
magnesinm equal to 23 grains of the lactate, so that the 
latter quantity, if suitably dissolved in the acids of the ali¬ 
mentary canal, is sufficient to produce a characteristic effect 
upon the blood. Now it is interesting to note that for a long 
time past it has been the custom in the treatment of urticaria 
and other allied affections to associate the carbonate of mag¬ 
nesium with the bicarbonate of sodium and potassium together 
with bitter infusions, remedies which undoubtedly stimulate 
the secretion of gastric juice. The supposition that magnesia 
is beneficial by saturating acids suggested to be in excess in 
the alimentary canal seems untenable in view of our present 
knowledge as to the action of these associated remedies. 
There can be little doubt that urticaria, for example, depends 

The Lancet, 


upon an effusion of serum into the tissues connected with a 
deficient coagulating power In the blood, though why in this 
instance the effusion is determined to the skin is unexplained, 
and that successful treatment involves an increase in this 
coagulating power seems well established. Therefore in this 
Instanoe old empirical practice finds a justification in modern 
research. Though not prompt enough for treating the emer¬ 
gencies of haemophilia, the continued use of the carbonates of 
magnesium and lime when properly associated with other 
drugs which procure their solution in the alimentary canal, 
seems quite sufficient for the treatment of other disorders 
of the kind indicated. 

Magnesium sulphate, in strong contrast to other salts tried, 
seems to be quite without effect in increasing the coagula¬ 
bility of blood, even in non-purgative doses. This has been 
previously ascertained, I believe, by Dr. Paramore. 

Bromide of strontium is not a convenient drug to experi¬ 
ment with on account of its soporific effect but seems to 
share with the lactate the property of increasing coagula¬ 
bility. Two examples will suffice. A dose of 15 grains in 
my own person produced a reduction from 1 j to lj minutes 
in the course of 1£ hours, and again on another occasion the 
same dose proonred a reduction from 1| to 1{- minutes in 
the course of one hour, a trifling effect but corresponding to 
an equivalent dose of lactate. 

Laetophosphate and glycerophosphate of lime are two 
soluble modifications of the phosphate of calcium which 
have been proposed for use in medicine with a view of more 
effectually introducing this substance into the economy. 
My experience with these two drugs may therefore be read 
with interest. One would have thought that as the lime in 
milk is principally present as phosphate and is a most 
important factor in the phenomenon of coagulation by 
rennet the same substance would play an important part in 
the coagulation of blood; and again, that if introduced in 
an extra quantity into tbe blood some manifest effect of 
its presence would have been produced. I find, however, 
that the laetophosphate and tbe glycerophosphate appear 
most inert bodies. I have administered them both to myself 
and to patients in doses far exceeding those employed medi¬ 
cinally with little or no effect. Experiments with tbe 
laetophosphate were somewhat cursory as the salt is cot 
very soluble, 10 grains requiring 2 to 3 ounces of hot water 
for solution ; doses taken in the solid form, however, of 
15 to 30 grains produced no perceptible result. With the 
glycerophosphate more extensive trials were made ; as an 
example of which I may record the following exhaustive 
test. On a certain day of the present year I took 30 grains 
of the glycerophosphate of lime dissolved in water at 
4.40 P.M , my coagulation time being then 2 minutes exactly, 
and at 5.40 p.m. tbe time was unaltered. On tbe next 
day at 5 30 p.m. the time was If minutes, showing perhaps 
a trifling result from the previous day ; another 30 grains 
were then taken, and at 6.15 the time was 1 minute 
50 seconds. On the third day a third dose of 30 grains was 
taken at 5 p.m., the coagulation time being again 1 minute 
and 50 seconds, and at 7 P.M. the time was exactly the same. 
The figures here shown exhibit the uniformity in the rate of 
coagulation maintained in the blood of a healthy man, and 
also the great exactitude obtained with practice with 
Wright's capillary tubes in testing this phenomenon. A 
clear day was then allowed to elapse and on the fifth day 
of the experiment the blood was again examined, and the time 
found to bs slightly over 2 minutes. The large quantity 
of 90 grains of a reputedly aotive salt had therefore been 
taken without any manifestation of what one would expect 
to be its principal effect. An equivalent quantity of the 
lactate would, as I know by personal experience, have given 
a very different result. Four whole days were then allowed 
to elapse, during which the coagulability of the blood was 
intentionally lowered by the free consumption of oranges, 
and the test was then resumed. The day after this interval 
tbe coagulation time was taken and found to be 2 minutes 
and 40 seconds, a condition similar to what is found in 
nrticaria; 45 grains of the glycerophosphate were then taken 
at the hour of 6 p.m. and by 7.30 the time had become 
reduced to 2 minutes. On the next day at the same hour the 
remarkably short period of 1^ minutes was recorded without 
any more of the salt having been taken, but on the succeed¬ 
ing and final day of the experiment the blood had returned 
to the old figure of 2 minutes. The second trial, therefore, 
seemed to have produced an effect, though of a moderate 
amount compared to the dose taken. 

Tbe conclusions arrived at with regard to the drugs men¬ 
tioned in this paper being based on experiments carried 

out with similar thoroughness to this one, though they are 
not all here recorded for want of space, I feel entitled 
to express the opinion that these two drugs, the glycero¬ 
phosphate and laetophosphate of lime, though so much 
vaunted pharmaceutically, are drugs which in the doses in 
which they are usually prescribed can have little effect if 
they are assimilated at all. I may add that the assumption 
of this large quantity of glycerophosphate, amounting to 
135 grains in a few days, produced no sensible effect whatever 
on my internal economy, neither disturbance of digestion nor 
of any other function resulting. At the same time I have 
evidence which is not yet complete that phosphoric acid and 
some of the soluble phosphates have an influence on the 
coagulating power of the blood, at any rate in bringing it up 
to normal, which goes to show that if these phosphates of 
calcium were absorbed they would be active also in the same 
direction. In the course of the routine testings of the 
haemophilia patient so ofteD mentioned it was found that 
upon half-drachm doses of Easton's syrup which had been 
prescribed by Sir Almroth Wright as a tonic, the coagulation 
time, which was generally in the neighbourhood of three 
minutes, came up to normal and there remained for some 
weeks with prevention of the usual hsemorrbages until the 
effect wore off, when recourse had to be had to magnesia 
or some other remedy. All the samples of Easton’s syrup 
which I have been able to analyse have contained 
the large quantity of the equivalent of 18 minims of 
the dilute phosphoric acid of the Pharmacopoeia in 
each fluid drachm which is apparently necessary to keep 
the other ingredients in solution—a fact perhaps not 
known to those who are fond of prescribing this unpalatable 
preparation and which makes it decidedly injurious to the 
teeth. Discriminating tests showed that it is the phosphoric 
acid which has the effect of improving the coagulability of 
blood, though bow it acts I am not prepared to say. Certain 
phosphates have the same effect, but as my observations in 
this respect are not complete I need refer to them no further 
than to say that they lead me to the conclusion that the 
laetophosphate and glycerophosphate of lime are so com¬ 
paratively inert because they are not absorbed as a matter of 
fact, though soluble in a test-tube. In this respect the 
alimentary canal would seem to be decidedly selective, as 
witness the case of the sulphate of magnesium. 

Of the salts of the alkaline earths my conclusion is that 
none come up to the lactates and chlorides and carbonates 
if duly assimilated, and that we should rely on there for the 
treatment of hemophilia. For urticaria and conditions of 
general debility there perhaps is a larger selection. 
It may be noted that the relation of lime to magnesia 
in the serum of blood is about that which is main¬ 
tained in natural calcareo-magnesian waters—that is, 
the lime is to the magnesia as 2 to 1. Hammarsten’s 
“ Physiology,” English edition, p. 201, gives a table 
which shows that the amount present in various serums 
is very constant, ranging from 0 06 to 0 • 09 per 1000 parts 
for the calcium, and 0 02 to 0-03 for the magnesium. In 
the complete blood, for which I have not been able to find 
any analyses distinguishing these two bases, the amounts 
must be larger, though doubtless in the same proportions, as 
they are both probably ingredients in the dot. A little more 
light on this subject would be useful; as anterior to the 
researches whioh have been carried on in Sir Almroth 
Wright’s laboratory I am not aware that any one had found 
a use for the magnesium present in the blood in a quantity 
which relatively is large. Doubtless strontium is able to 
replace either of these bases when deficient, in a manner 
conformable to its chemical relations, and so is not toxic, 
though not a natural ingredient of the body. 

Gloucester-road, S.W. 




The patient was a Mahomedan woman, aged about 29 
years, who came to the Victoria Zenana Hospital, Delhi, 
oomplainingof enlargement of the abdomen. The history of 
the case (as suoh histories generally are in India) was 
untrustworthy, but it appeared that she had had some enlarge¬ 
ment for four years. A year before admission she bad given 
birth to her fourth child. Since then the abdomen had been 
increasing in size up to the time when treatment at hospital 
was sought when it was very muoh enlarged and tense, the 


umbilicus being unfolded and the patient being unable even 
to sit down with comfort. Large veins were visible over the 
swelling and the skin was stretched to what looked like the 
cracking point. The patient was emaciated and she looked 
haggard and had an anxious expression. Breathing and move¬ 
ment were alike impeded and painful. She had come from a 
village 14 miles away, but.the idea of staving at the hospital 
proved so objectionable to her that she returned to her home. 
In a week she came back again begging to be admitted. 
She was in great distress, could scarcely breathe, and move¬ 
ment was all but impossible. The abdomen was apparently 
larger than before. The fulness extended to, and filled out, 
the flanks and went down to the pelvis so that it stood 
out from the lower ribs which were pressed out and hung 
over the pelvic bone. The tension was so great that no 
organs could be palpated. The heart was displaced ; the 
apex beat was heard best in the second space three and a 
half inches from the mid-sternal line. The lungs on per¬ 
cussion were found to be squeezed into a contracted 
space at the upper part of the thoracic cavity. From the 
third rib downwards it was not possible to distinguish lung 
sounds as the tumour occupied the whole space. The pulse 
was running and weak and the patient was too ill for any 
exhaustive examination to be made. She was in such 
distress that a preliminary tapping was done and four 
quarts of a greeniBh-yellow slimy fluid were withdrawn. 
Unfortunately this was thrown away before examination. 
The vaginal vault was found to be bulging downwards and 
full; and the uterus was pushed down, but was normal. No 
other organs could be distinguished. Dr. Jenny C. Muller 
of St. Stephen’s Hospital, Delhi, was called in, in consulta¬ 
tion, and a laparotomy was decided upon, the provisional 
diagnosis of ovarian cyst having been made. 

Four hours after tapping the abdomen was full and taut 
again. On the next day the patient, having been duly pre¬ 
pared and presenting a more favourable condition with a 
slightly better pulse, wasoperated upon. The ordinary incision 
was made in the abdominal wall. When the skin and fascia, 
&.O., had been divided it was found impossible to pick up 
and to divide the peritoneum. Indeed, the usual appear¬ 
ance of the peritoneum was not to be Been. Instead, a thin 
dull layer closely adherent to a thick tough wall was found. 
It was not possible to separate the two, so the thick wall was 
incised. It was at least a quarter of an inch thick and very 
tough. Its inner surface was rugose. On incision a large 
quantity of the greenish-yellow glairy fluid escaped. On 
inserting a hand into the cavity thus opened several round 
tumours were encountered. They were slimy balls filled with 
a transparent opalescent fluid. They varied in size from that 
of a pin's head to the dimensions of a football. They ocoupied 
the cyst from the level of the third rib down into the pelvis. 
The cyst contained several pockets separated from each other 
by strands of connective tissue which were broken down with 
difficulty. 200 cysts were counted and at least as many more 
were fonnd burst or escaped in the fluid used to wash out the 
cavity. The burst ones had their walls rolled up in scrolls 
and were in some cases packed away under the bigger cysts. 
The walls were slimy and transparent and varied in thickness 
with the size of the cyst. The bigger cysts showed daughter 
and grand-daughter cy6ts. On the lining membrane were 
found Bcolices on subsequent microscopic examination. The 
fluid was opalescent and bad a faint odour. It took some 
time to empty all the pockets, as they were up in the 
thorax and against the posterior wall. An attempt to 
separate the peritoneum from the thickened cyst wall was 
unsuccessful, nor was it possible to determine the seat of 
origin of the cyst, though the liver was suspected. The 
cavity was well washed out with saline solution and a drain 
left in in the lower part of the wound. In two dayB the 
heart came down and the apex beat was heard and felt in the 
fourth space; gradually the other organs resumed their 
usurped positions. The cavity was washed out daily with 
saline solution and a drain left in. At first this was a long 
tube, later a gauze drain was sufficient. Three weeks after 
the operation the patient had a rise of temperature, following 
on a couple of days of malaise. The wound bad an unpleasant 
sweetish odour. In the daily dressing another cyst was 
found and evacuated. It came from the left lobe of the liver. 
The patient improved steadily till five weeks later, when she 
had a similar rise of temperature with extreme tenderness in 
the region of the left lobe of the liver. Her breath had a 
sweet “apple’’odour and the wound smelt the same. A 
brilliant green pus exuded from the wound. On microscopic 
examination this showed the bacillus pyocyanus. As saline 

solution alone was used for her daily irrigating and an iodo¬ 
form dressing applied it was found impossible to account for 
this. She was put on alkalies and improved rapidly ; the 
wound was cleaned out. The cavity continued to diminish 
in size. Four months after the first operation a second was 
done as white cyst-wall material was seen in the discharging 
sinus. This was scraped. The patient then improved without a 
break. She was given hoematogen fora time but soon was 
in such splendid condition that she was able to do without it. 
The cavity closed entirely, the patient put on flesh rapidly, 
and went home looking 20 instead of 50 as she did on admis¬ 
sion. She came from a village and described her hut and 
surroundings as being occupied by dogs, sheep, and cattle, 
as well as her family. The open stream from which they got 
their water was common to men and beasts. 

Delhi. _ 


Bt ARTHUR MAUDE, M.R.C.S. Eng., L.R.C.P. Lond. 

Complete inversion of the uterus is so rare that its occur¬ 
rence justifies notice and some remarks on the subject. I 
was hastily summoned to a young woman in labour of her 
third child. The so-called “ midwife ” in attendance realised 
that something serious bad happened but had no idea of its 
nature and thought that the patient was dead. She was 
nearly so, having no pulse at the wrist and being in a state 
of almost complete unconsciousness from Bhock. There had 
been very severe haemorrhage but it had almost ceased when 
I arrived. The uterus was completely inverted, lying quite 
outside the vulva. The cord had been separated near the 
umbilicus but was not abnormally short. The woman was in 
such a pool of blood that it was not easy to realise what bad 
happened in a few secondsthe point that gave me the clue 
at once was the feel of the round ligaments on each side, 
which were dragged right down to the most external part of 
the uterus, which was the fundus, capped by the placenta. 
Two important points I noted without at the time realising 
their importance. First, that the oord was thin and frail; 
if traction had been made on the cord sufficiently powerful 
to invert the uterus it is probable that it would have broken 
close to its placental attachment; this it had not done and I 
regard its condition as better evidence that undue traction 
had not been employed than the statement made (in answer 
to my questions) by the midwife that she had not employed 
it. Secondly, the polar position of the placenta was absolute; 
the placenta lay attached to the inverted fundus as if it had 
been placed by design in the axis. This observation is con¬ 
firmatory of the view expressed by Hennig 1 many years ago 
that the active cause of this disaster is an absolutely polar 
attachment of the placenta. 

The history of this case as given by the midwife and after¬ 
wards by the patient was that the labour had been quite 
natural and rather rapid. There was no straining effort or 
unusual position assumed by the mother daring labour. Both 
women agreed that the child, which presented head first, was 
born rapidly at the last and that the placenta and uterns came 
out together immediately after it. I found the placenta very 
large and adherent except at the edges ; so, considering the 
very grave condition of the woman and thinking that she 
would stand no prolonged manipulation, I decided not to try 
to reduce the placenta with the uterus but to risk its 
detachment. I peeled it off with the left hand, gently 
reduced the axis of the fundus first, and, fortunately, 
restored the whole organ without difficulty. Having a very 
small hand 1 followed the fundus up and kept my hand in 
the cavity till good contractions began to become constant, 
which was after about ten minutes ; during this time and 
for three hours after I kept up massage through the 
abdominal wall. Probably not more than a quarter of an 
hour had elapsed between the inversion and my arrival and 
dealing with it. Hence I found the spasm of the inverted 
ring of Bandl very slight and the ease of reduction propor¬ 
tionate. There was no serious amount of haemorrhage after 
the uterus was restored to its proper position. It is un¬ 
necessary to detail the treatment for shock and loss of blood 

1 I’eber die Ursachen der Spontanea Invenlo Uteri, Arcbiv far 
Gyn&kologie, Band vil., p. 491. 


The value of this case depends on the points to which 
attention has been directed ; the inversion was complete ; the 
position of the placenta and its large size, coupled with the 
absence of evidence of artificial production, tend to support 
the theory of Hennig to which reference has been made. 
The patient made an excellent recovery and there was no 
tendency to secondary chronic inversion. 

Complete inversion of the uterus is extremely rare. Braun 
had never seen a case in 160,000 births. In Kamsbotham’s 
tables of 50,000 births the accident is not even mentioned, 
and it seems doubtful if in 1847 it had even been recognised. 
From 1745 to 1860 at the Rotunda in 191,000 deliveries it 
had only once been observed. 



By R. KINGSTON FOX, M.D. Brux., M.R.C.P. Lond., 


The object of this paper is to record observations made on 
the coagulation time of the blood in the puerperal condition. 
The observations were made by Wright's method, modified 
by the author, and a correction has been introduced for 

Method .—Sir A. K. Wright’s apparatus is described and 
figured in The Lancet of Oct. 14,ti, 1905, p. 1096. I have 
after experience dispensed with the mercury, the segmenta¬ 
tion of the tube, and its hair-fine tapering end, and the 
method used by me is as follows 

The apparatus consists of a series of capillary tubes, eight centi 
metres in length, and each of such calibre that five cubic millimetres of 
mercury fill it to the length of five centimetres; each tube is inserted, 
the smaller end outwards, into a short larger tube aud fixed in its 
place in an air-tight manner by sealing wax. Rubber nipples 
to fit the tubes, a beaker of water standing on white paper, 
a spirit lamp, an accurate thermometer, and a piece of 
string are provided. Pour of the tubes are taken in succession and 
nearly filled with blood from a puncture near the end of the finger or 
thumb. Care should be taken that the blood flows freely, as squeezing 
the finger is apt to cause lymph from the tisanes to be mixed with the 
blood, leading to an increased coagulation time. Nor must the finger 
be ligatured, as this much lessens the coagulation period. The blood 
lying in the tube should not quite reach either end of it. Each tube 
as soon as filled is laid on the table in order by the side of the 
thermometer and the exact time of drawing the blood from the finger 
noted on paper. The finger is then wiped and the puncture closed, 
until after an interval of 30 seconds or more the next tube is applied 
and the time noted. When all four tubes have been filled the 
obeerver decides at what Interval he will examine the first tube, com¬ 
mencing well under the expected coagulation period. A rubber nipple 
is applied aud the blood in the tube expressed into the water. If the 
mass is readily diffused the next tube may be left for one or two 
minutes longer than the first. The process is repeated until either a 
defined wormlike clot is expelled, which retains its form for some 
seconds, or until the contents have become so dense that they are with 
difficulty expressed. This occurs in Borne cases apart from the forma¬ 
tion of a red wormlike clot, the mass being partially diffusible in the 
water. The reason of this variation is probably the admixture of 
coagulable lymph. At present I reckon the coagulation time to be the 
time which elapses before either a wormlike clot is formed or else the 
tube is with difficulty emptied, whichever happens first. Should the 
nipple fail to expel the contents the string should be wound tightly 
around the lower part of the nipple and then persistent efforts in com¬ 
pressing it will generally succeed in emptying the tube. If this cannot 
be done the tube must be discarded. I have not found any means of 
cleansing a tube when once choked. 

Sir A. E. Wright accounts the coagulation time to be com¬ 
pleted before the first appearance of a shred of fibrin forma¬ 
tion. This appearance is seen much earlier and I think 
may sometimes be accidental, due to the presence of a minute 
quantity of blood less freshly drawn or of skin tissue or other 
extraneous matter. It seems to me better to wait nntil the 
entire mass of blood is coagulated. As by this means we 
obtain a much longer coagulation period than Sir A. E. 
Wright’s the figures are not comparable with his. 

Correction for temperature. —Five observations in immediate succes¬ 
sion were made on a healthy man, aged 22 years, whose puUe was 72, 
regular; arterial pressure 100 degrees (Hill and Barnard). The blood was 
known to have an over-average coagulation time. The tubes when 
filled with blood were placed in small test tubes, weighted 
with mercury, and plunged into ft water bath of a capacity 
of about two litres. The water was maintained at a given tem¬ 
perature—viz., 40°, 50°, 60°, 70°, and 80 s F. respectively—in the five 
observations. It had previously been ascertained that the temperature 
of the air within the test tubes at several readings accorded closely, in 
each case, with the temperature of the water in the bath. The follow¬ 
ing results were obtained. Coagulation time at 40° K., 16 minutes ; at 
60", 10 minutes 45 seconds; at 60°, 8 minutes 30 seconds; at 7C°, 
7 minutes30 seconds; at 80°, 6 minutes 40 seconds. On plotting these 
out to scale the coagulation time is seen to form a curve, the ordinates 
of time incressing greatly as the temperature descends towards freezing 

C 'ot, to which line the curve doubtless forms an asymptote. A curve 
been found which closely approximates to this between the tem¬ 
peratures 40 9 to 80° F., but I have not yet obtained a formula for 

reducing observations to the standard temperature of 60°. This 
correction must therefore be made from the diagram graphically. 

Obsirvations on blood coagulability in the puerperal state .— 
By the kindness of Dr. W. J. Gow, physician to Queen 
Charlotte's Lying-in Hospital, I have made observations on 
the blood of eight parturient women during the first week 
after delivery in the wards of that hospital. All were primi- 
pane ; unmarried, except the patients in Cases 2 and 8 ; the 
labours were normal, bat in Cases 1, 3, 5, 7, and 8 they were 
tedious ; haemorrhage was normal; all suckled their infants, 
who appeared to be healthy. In Case 4 there was a trace of 
albuminuria and the temperature rose to 100 ■ 2° F. on the 
second day, the pulse-rate being 108 ; milk on the fifth day 
was rather deficient. Gonorrhoea was present in Case 1. The 
observations were taken between the hours of 2 30 and 6 P.M. 
The patients were, of course, recumbent in their beds. The 
results, corrected for temperature, are as follows, the period 
required for complete coagulation being represented in 

minutes : 

Years of age. 



Case 1 

... 26 ... First day 

... 4 ... Fourth day 

... 64 

.. 2 

... 25. 

... 5. 

... ■84 


... 22. 

... 5i ... Fifth 

... 64 


... 21. 

... 64. 

... 74 

.. 5 

... 28 ... Third „ 

... 64 ... - 



... 20. 

... 64 ... Seventh „ 

... 64 


... 23. 

... 54. 

... 74 

.. 8 

... 23 ... Seventh,, 

... 7 ... — 


The observations may also be summarised as under :— 

First day 
Third day 
Fourth day 
Fifth day 
Seventh day. 

Four observations 
.. Three „ 

.. Two „ 

.. Two ,, 

.. Three 

4, 5, 58, 6i minutes. 

64, 64. 54 
64, 74 
7. 64, 74 

Comparing these figures with many other observations 
taken by the same method I find that the coagulation time 
immediately after delivery is below the normal but not to 
the same extent as is commonly supposed. For I have often 
found a much lower coagulation time in adults, as low as 
three minutes or less. Five and a quarter minntes, the 
average time on the first day after confinement, is not 
therefore very low. Perhaps under the careful management 
of labour in the hospital the haemorrhage is less, and so the 
blood coagulability is less altered on this account. It will 
be noticed that in every case in which two successive obser¬ 
vations were taken the coagulation time had increased 
during the interval. The excretion of calcium salts In the 
milk tending to reduce the coagulability of the blood was 
probably one cause of this increase. 

An observation of the coagulation time of the blood after 
delivery might give useful warning : of the risk of thrombosis 
or embolism if the coagulation time were low, or of post¬ 
partum haemorrhage if it were high. Appropriate treatment 
—for example, with citric aoid on the one hand or with 
calcium lactate and salines on the other—would rectify the 

I made a few observations on some of these women during 
the latter part of pregnancy and subjoin them for what 
they are worth. So far as they go, they indicate a tendency 
to a low coagulation time, in several cases lower than after 
delivery. 1 The blood during pregnancy is probably rich in 
nutrient matter required for the growth of the foetus. 
According to Winckel, it has a somewhat diminished 
alkalescence and exhibits a more ready (mdtrige) leucocy- 
tosis. Bar and Daunay state that the density of the blood 
is diminished at the end of pregnancy but rises again after 
partns. My observations of the coagulation point were made 
under varions conditions as to time of day and relation to 
exercise and to meals, contrasting with the even conditions 
attaching to those made in the wards of the hospital. 

Obeervatiom on the Same Cruet during Pregnancy. 

C«18« 1 ... . 

11 days before partus ... . 

4i minutes. 

„ 2 ... . 

.. 18 „ ... . 

■ n „ 

„ 3 ... . 

.. 31 „ 

2S ,. 

„ 6 ... . 

.. 54 „ 

. 74 

„ 7 . 

.. 47.. ... 

• 14 .. 

I have not found any reference to the coagulability of the 
blood in pregnant or puerperal states In recent workB on 
obstetrics, BritUh, French, or German. 

Weyinouth-street, W. 

1 Compare Dr. Blair Bell's reference to the presence of large 
quantities of calcium salts in the systems of pregnant women, Brit. 
Med. Jour., April 20th, 1967, p. 921. 


Clinkal Jtoks: 



By James Pihie, M.A., M.D. Aberd. 

On Oct. 12th, 1907, a woman, aged 43 years, was delivered 
of an acranial foetus. The entire vault of the cranium was 
absent and the floor of the gap thus caused was formed by the 
basilar process of the occipital bone. The scalp was intact 
and formed a coil on the top of the vacuity. The brain was 
almost entirely absent but the medulla oblongata was 
present. Along with a rudimentary pons Yarolii several of 
the cranial nerves could be recognised at the base of the gap. 
On Nov. 7th a woman, aged 38 years, in the same village, 
was delivered of a similar fcetus which also showed a spina 
bifida. Both fuctuses were otherwise well nourished and not 
malformed in any other way. The former one was extremely 
large and weighed 10J pounds. 

An interesting feature, and adding to the extraordinary 
nature of the coincidence of time and place, was that both 
mothers had very large goitres, and one at any rate had taken 
a great number of a certain advertised pill warranted to 
remove “ female irregularities.” 

Hmrbury, Leamington Spa. 


By E. S. Crispin, M.R.C.S. Eng., L.R C.P. Lond., 


The accompanying illustration is a reproduction of a 
photograph of a case of hermaphrodism and may be of some 
interest to readers of The Lancet. I am unable to say if it 
is a case of true hermaphrodism or false, most probably the 
latter, of the masculine type. The patient's features are 
masculine; he has enormous breast development, as is well 
seen, but without any known secretion of milk ; his pelvis is 

of a masculine type. His genitals consist of a very small 
penis with complete hypospadias. The scrotum is cleft with 
a very small testicle (?J in each half. He informs me that he 
has been married some time and is able to perform the act 

of coitus but has no children. His voice is distinctly 
falsetto. He was engaged in work as a male messenger. 

Port Soudan, Red Sea. 


By A. 0. D. Firth, M.A. Cantab., M.R.C.S. Eng., 

L R C.P. Lond., 


As cases of gangrene caused by carbolic acid are now 
somewhat uncommon the following case is of some interest. 

The patient was a thin, anaemic girl, aged 16 years, who 
while at work on Nov. 20th, 1907, ran a wooden splinter a 
short way under the nail of the right ring finger. The 
splinter was extracted and a carbolic acid compress of un¬ 
certain strength was applied to the finger at the factory in 
which the girl was working. The compress was applied at 
8 30 p.m. and remained on until 11.30 a.m. on the next day, 
and after removal the finger was found to be cold, white, and 
acaistbetic. There was no sensation of tingling or numbness 
while the compress was applied to the fiDger. On the 23rd 
discolouration began and the girl attended the West London 
Hospital for the first time on the 25th. On that occasion the 
skin as far as the proximal interpbalangeal joint was black 
and insensitive, the last two phalanges being in a state of 
dry gangrene, of which the line of demarcation was appa¬ 
rently well established. No carboluria had been noticed. 
The finger was disinfected as far as possible and wrapped in 
dry dressings, but these precautions failed, the gangrene 
became moist, and it was eventually found necessary to 
amputate the finger at the metacarpo phalangeal joint. 

This condition, although described in all the text books, is 
comparatively rare, as the public have learnt, in many cases, 
the dangers of applying carbolic acid in this manner as an 
antiseptic "precaution.” No doubt the unfortunate person 
who applied it in this case will spread the warning as widely 
as possible. 


The Supports of the Pelvic Viscera.—Exhibition of Specimens. 

A meeting of this section was held on Dec. 12th, 1907, 
Dr. Herbert R. Spencer, the President, being in the chair. 

« Dr. W. E. Fothergill read a paper on the Supports 
of the Pelvic Viscera. He considered that the current 
teaching of gynaecological anatomy, while correct in a 
general sense, lacked that accnracy which was essential if 
the student was to have a real grip of his clinical work. It 
was generally assumed that the urino genital organs were 
partly suspended by the so-called ligaments of the uterus 
and partly supported from below by the pelvic floor. But the 
perineum and the pelvio diaphragm were often seriously im¬ 
paired by injury or loss of tone without any consequent change 
in the position of the pelvic viscera, which showed that 
support from below was not essential. Again, during abdo¬ 
minal operations the ligaments of the uterus were seen to lie 
loose and slack upon the subjacent structures and to have no 
supporting aotion whatever. The operation of vaginal 
hysterectomy afforded confirmation of these observations 
and revealed to the clinician the fact that the uterus was 
really supported by the sheaths of its blood-vessels which 
attached it firmly to the sides of the pelvic diaphragm. In 
the same way the vagina and the bladder were held in posi¬ 
tion by the sheaths of their blood-vessels, the rectum 
having an independent attachment to the back of the 
pelvis. Thus lengthening and laxity of the sheaths of the 
blood-vessels was the one constant and essential factor in 
the causation of prolapse of the pelvio vicera. Dr. Fothergill 
considered that while gynecologists were well aware of these 
facts they refrained from teaching them, because they 
borrowed their anatomical statements from the writings of 
professed anatomists. He therefore went on to show by 
quotation from recent papers by anatomists of the first rank 
that descriptive anatomy had changed in a way exactly parallel 

The Lancet 


to that in which clinical gynaecology had moved. The utero- 
sacral ligament was a mere peritoneal fold ; the broad 
ligament was simply a mesosalpinx and mesovarium. The 
ronnd ligament was a vestigial structure, the homologue of 
the gubernacnlum teBtis, which pulled down the ovary and 
uterus in early foetal life, and by no means supported them 
during post-natal life. The superficial perineal muscles 
derived from the primitive sphincter cloacae had a sphincteric 
and not a supporting action. The muscles of the pelvic 
diaphragm were vestigial structures, being the degenerated 
representatives of the powerful tail-moving muscles of lower 
vertebrates. Their muscular action was largely lost ; but, 
by virtue of their position, they, with their fascial coverings, 
formed the funnel-shaped musculo-membranous structure 
known as the pelvic diaphragm. This could not support the 
plastic pelvic viscera, either by its shape or its muscularity, 
if the pelvic viscera were not firmly attached to its sides. 
The conception of the pelvic fasciae as independent and 
definite structures must be given up, and the fascim must be 
regarded simply as the connective-tissue coverings of the 
muscles, the viscera, and the blood-vessels. The vessels and 
their sheaths, together with the ureters, nerves, and 
lymphatics, formed masses of tissue which extended between 
the sides of the pelvis and the lateral aspects of the uterus, 
bladder, and vagina, and which held these structures in 
position. The rectum was independently attached to the 
back of the pelvis, and lay loose in a channel between the 
vessels of the right and left sides. It was free from the 
urino-genital organs and did not descend with them in 
prolapse unless the anterior rectal wall was pathologically 
adherent to the posterior vaginal wall. 

The President thanked Dr. Fothergill for the interesting 
and lucid communication which he had brought before the 
section. Although the question of the support of the pelvic 
viscera was one to be settled by anatomical research, anyone 
who had performed total abdominal hysterectomy and had 
noticed the ‘ 1 ligamentum transversals colli ” which lay at 
a lower level than the uterine artery and was very dense in 
structure, would find it difficult to accept the statement 
that it was the sheath of the vessels which kept the uterus 
in place. Also, how could the bladder be kept up by the 
sheath of the vessels which were small in number and size 1 

Dr. Amand J. M. Routh congratulated Dr. Fothergill 
on his lucid and excellent discourse and felt that it 
would be greatly to the advantage of both students 
and gynaecologists if the antiquated views so long held 
on the subject of the uterine supports were replaced by 
those now elaborated. He thought that Dr. Fothergill 
had succeeded in proving his contention that the uterus 
was mainly supported by the perivascular connective- 
tissue bundles above the pelvic floor. He bad put into 
words much of the scepticism which gynaecologists had held 
as to the acceptance of the orthodox views. No one who was 
in the habit of opening the abdomen and of seeing the 
flaccid broad ligaments and the redundant circuitous round 
ligaments could hold the view that these structures supported 
the uterus, whatever might be thought of the functions of the 
utero-sacral ligaments. He had long held the view that the 
connective tissue in the bases of the broad ligament and 
utero-sacral folds (which really unite and form one common 
connective-tissue bundle at their junction with the supra¬ 
vaginal cervix) were very important agents in holding down 
the uterus to the floor of the pelvis. If in amputating the 
cervix per vaginam these bundles were cut through, the 
freed uterine body could not only be easily drawn down¬ 
wards by traction but would be spontaneously elevated 
behind the pubes if not held down by vulsella forceps. 
He thought, therefore, that the bundles of connective tissue 
grouped round the vessels and the ureters served rather as 
anchors to fix the uterus down to the pelvic diaphragm, pre¬ 
venting undue mobility both upwards and downwards. The 
normal anteversion of the uterus was doubtless maintained, 
according to Dr. Fothergill’s view, by the perivascular 
sheaths suspending the supravaginal cervix from a direc¬ 
tion upwards and backwards (in the erect position), much in 
v;he same way as the utero-sacral folds had been hitherto 
supposed to act. He hoped that Dr. Fothergill’s views would 
receive general attention and acceptance. 

Dr. R. H. Paramore disagreed with what had been said 
by Dr. Fothergill. In determining the position of the 
uterus and the maintenance of this position in the pelvis 
they had to consider not only the structures which united the 
uterus to the pelvic wall and the pelvic floor itself but also 
the intra-abdominal pressure which had a definite influence 

upon the position of the pelvic viscera. The intra-abdominal 
pressure depended upon the capacity of the abdomen, the 
volume of the abdominal contents, and upon the condition 
of the contraction of the muscles which enclosed and formed 
its boundaries. Dr. J. Matthews Duncan had laid stress on 
the retentive power of the abdomen and had drawn attention 
to the fact that the uterus did not alter its position as a result 
of complete rupture of the perineum alone, but if prolapse 
occurred other factors had come into play. In women with 
an undamaged pelvic floor and in whom the intra-abdominal 
pressure was much increased by a deposit of fat in the 
omentum or mesentery, the uterus was often found high up 
owing to the activity of the levator ani muscle. If in such 
cases the pelvic floor was damaged by childbirth, an 
inevitable prolapse resulted. 

Dr. Briggs believed that too much was attributed to 
ligaments. The muscular and tendinous and other fibrous 
tissues around a joint controlled its security and mobility 
and produced its stiffness. The ligaments of the pelvic 
viscera were insignificant compared with the mass of the 
muscles and their fascia, the fibrous packing between, and 
the fibrous envelopes of, the viscera and canals. 

Sir Arthur V. M acan said that the importance of the pelvic 
connective tissue was pointed out years ago by W. A. Freund 
and more recently a firm band in the lower part of the broad 
ligament at each side of the cervix had been differentiated 
by Kooks under the name “pars cardinalis ligamenti lati.” 
The effect of taking away the support from below could often 
be observed clinically in cases where prolapse of the anterior 
vaginal wall followed rupture of the perineum. As the 
vaginal wall prolapsed it drew the cervix downwards and 
forwards which produced backward displacement of the 
fundus and, finally, prolapse. Prolapse of the uterus 
was also met with in old women due to senile atrophy 
of the pelvic connective tissue removing the natural 
support of the pelvic organs. The strength of the support 
from below was, he thought, well shown by the resistance 
which the pelvic floor offered to the expulsion of the child’s 
head during labour. 

The following specimens were shown :— 

Dr. C. Hubert Roberts : A Cancerous Uterus and Glands 
removed by Wertheim’s Method. 

Dr. Peter Horrocks : Tuberculous Disease of the Cervix. 

Dr. James Oliver : A Somewhat Unique Tubal Gestation. 

Dr. Lewers : Sarcoma of the Ovary complicated by Car¬ 
cinoma of the Body of the Uterus ; Operation. 


Exhibition of Catet. 

A meeting of this section was held on Dec. 19th, 1907, 
Dr. T. Colcott Fox being in the chair. 

Mr. G. W. Dawson showed a case for diagnosis. The 
patient was a woman, aged 33 years, who had had for the 
past six years an affection of the skin which had slowly 
spread from the palms and soles to occupy the forearms and 
legs. These parts were reddened, slightly thickened, and 
scaly, presenting a finely rugose surface. The diagnosis was 
not clear. 

Dr. Colcott Fox showed a woman with Verrucose Granu¬ 
lomatous Swellings on the Upper Lip, the Nose, the Chin, 
and Nasolabial Furrow. These had persisted for three 
months. There was no history of syphilis or tubercle and 
she had not been taking any drugs that could be held respon¬ 
sible for the appearances. A yeast-like fungus had been 
found in scrapings, and the possibility of its being a case oi 
blastomycosis was suggested.—Others contended that it was 
a verrucose sypbilide. 

Dr. E. G. Graham Little showed: 1. A case of Favus of tho 
Scalp and Nail in a woman, aged 40 years, who had never left 
England and was a native of Essex. Very numerous and 
typical scutula were seen on the scalp and the fungus was 
readily found in the hair. A nephew, aged eight years, living 
in the house had apparently contracted the disease from the 
previous patient and when shown had very numerous 
pityriasic and alopecic patches, the result of the disease on 
his scalp. 2. A case of Bazin’s Disease of unusually rapid 
development in a young woman, the legs having numerous 
deep-seated ulcers and nodose swellings which dated from 
only two months previously. There was no history of pul¬ 
monary tuberculosis and the tuberculo-opsonic index was 0 96 
on the single occasion on which it had been examined. 

Dr. J. M. H. MacLeod and Mr. E. Treacher Collins 
(introduced) showed : 1. Three caiea of Keratosis Follicularis 

Th* Lancet,] 


[Jan. 11, 1908. 103 

notice that some of the species which hitherto had escaped 
notice were widely distributed, extremely frequent, and highly 
pathogenic. One of the worst scourges of the tropics was 
without doubt the endemic anaemia, now generally known as 
ankylostomiasis. In 1838 Dubini discovered the ankylosto- 
mum duodenale in the duodenum of a peasant woman who died 
at the Ospedale Maggiore in Milan. In 1851 Griesinger showed 
that Dubini's worm was the cause of Egyptian chlorosis. 
Later, Wucherer showed that the Brazilian disease called 
*' oppilatio ” was likewise an ankylostomiasis. The world¬ 
wide distribution of endemic anaemia indicated the possi¬ 
bility of more than one type of disease in the various regions. 
In 1888 Lutz noticed that the Brazilian worm was not 
provided with the hooked teeth described by European 
authors, and Stiles in 1902 showed that the endemic ansemia 
of America was not, as a rule, due to ankylostomum duo¬ 
denale but to a new species of the closely allied genus 
necator, for which he proposed the specific designation of 
11 Americanus,” believing it to be special to the American 
continent and the adjacent islands. Later, however, it was 
found by Loose in pygmies from Central Africa and by 
others in Assam, Burma, West Africa, and Italy, suggesting 
probably Africa or Asia as the original habitat. In 1905 
Baillet and Henry described another new strongyloid of man 
which, like necator Americanus, might also be an impor¬ 
tant agent in the causation of tropical ansemia. They 
discovered the new parasite in the collection of the Paris 
Natural History Museum. It was represented by two spe¬ 
cimens presented by Dr. Monestier in 1865 and collected 
at the post mortem examination of an African negro who died 
from endemic anaemia in Mayotte. Another new parasite, 
likewise belonging to the sub-family Sclerostominse, was the 
ociophagostomum Brumpti discovered by Brumpt in 1902 in 
Africa. Another group of parasites mentioned was that of 
the schistosomidse For a long time only one species was 
known to occur in man; it was the schistosomum haema¬ 
tobium, better known as bilharzia after the name of the 
investigator who discovered it in Egypt in 1851, and showed 
that it was the cause of endemic bsematuria. In 1904 
Professor Katsurada discovered a new species in Japan and 
called it schistosomum Japonicum. It was not recognised 
before probably because its ova lacked the characteristic 
spine of the eggs of schistosomum hasmatobium and 
greatly resembled those of ankylostomum duodenale with 
which they must have been frequently confounded. The 
adult parasites closely resembled those of schistosomum 
hmmatobium; the striking difference was the absence 
-of cuticular prominences on the outer surface of the body 
of the male. Schistosomum Japonicum did not affect the 
bladder; its ova were eliminated by way of the intestine 
and frequently accumulated in the liver, giving rise to a 
peculiar form of cirrhosis. A third species of schistosomum 
was described by himself (Dr. Sambou) last summer. He 
called it schistosomum Mansoni, because Sir Patrick Manson 
had already suggested the possibility of its specificity. 
The material at his disposal being scarce and badly pre¬ 
served, he had not been able to study their anatomical 
structure. He had noticed that the body surface of the 
male presented cuticular prominences somewhat similar to 
those of schistosomum haematobium, and he had pointed out 
-that the differences in the structure of the female genital 
tract described by Fritsch as abnormal were characteristic of 
the new species His determination was based chiefly, but 
not solely, on the characteristics of the ovum which in 
schistosomum Mansoni differed greatly from that of schisto¬ 
somum haematobium not only in the position of the spine but 
also in the size and shape both of the spine and of the body 
of the egg. His determination was based also on the peculiar 
geographical distribution and on the peculiar anatomical 
habitat of the new parasite. In Egypt both schistosomum 
haematobium and schistosomum Mansoni were found side by 
side, but the former appeared to be more prevalent and was 
certainly more conspicuous owing to the hmmaturia to which 
it gave rise. That was probably the reason why the two 
forms had been confounded, the spined ova of schistosomum 
Mansoni being looked upon as abnormal. They must go 
elsewhere to become aware that the differently shaped eggs 
represented two different species. Thus in the West Indies 
schistosomum Mansoni was the only species present, 
endemic hsematuria was unknown, and the parasite 
escaped observation until quite recently, when a sys¬ 
tematic examination of stools for the detection of ankylo¬ 
stomum ova made them suddenly aware of its extreme 
prevalence. Schistosomum Mansoni, like schistosomum 

Japonicum, never affected the bladder. Its ova were deposited 
within the submucous layer of the rectum. They had been 
found not infrequently in the liver, giving rise to a cirrhosis 
similar to that produced by schistosomum Japonicum. A new 
porocephalus and some new parasitic larvae of diptera were 
also mentioned. Then Dr. Sambon discussed the patho¬ 
genic action of metazoan parasites and spoke of the toxins 
which they produced. He drew special attention to the 
migrations of certain parasites in their larval or immature 
stages before reaching the anatomical habitat in which they 
were usually found, and he said he believed that such 
wanderings would explain much that was cow obscure in the 
pathogeny of certain species. Until quite recently the 
route followed by intestinal parasites was supposed to be 
a direct and simple one. The eggs of the parasite were 
swallowed by the host. They reached the intestine with water 
or food and hatched in the part most convenient. Likewise 
maggots found beneath the skin were supposed to have been 
laid in the very spot by the parent fly. The true mode of en¬ 
trance might be very different and complicated. At one time 
it was believed that hypoderma bovis, the ox warble fly, laid its 
eggs upon the back of cattle and that the larva imme¬ 
diately penetrated the skin and lived there without wander¬ 
ing. Now it was known that the fly laid its eggs upon the 
legs of cattle, especially just above the hoof. The animal 
licked its legs and the larva at once hatched and was carried 
down into the (esophagus, the walls of which it penetrated. 
It then wandered through the connective tissues of the host 
and found its way into the spinal canal. (In young cattle as 
many as 57 larvae had been found distributed throughout 
the whole length of the spinal canal.) Ultimately it reached 
a point beneath the skin on the back of the animal. Another 
example was that of ankylostomum duodenale. Until quite 
recently it was believed that the so-called encysted larva 
was swallowed with water, food, or possibly even earth. Thus 
it passed straight into the duodenum. Loose had suggested 
another mode of entrance through the skin. According to 
this investigator the nematodes pass with the blood through 
the heart to the lungs, from the lungs to the air passages, 
up to the larynx, down the (esophagus to the stomach, and 
then to the small intestine. Loose’s theory of skin infection 
had been thoroughly demonstrated by experiment but Dr. 
Sambon doubted whether the trachea-oesophagus part of the 
journey was mure than a mere conjecture. In cesophago- 
stomnm and in other sclerostomies; which inhabited the 
intestine when fully mature for the purpose of fertilisation 
and oviposition, the immature forms before entering the 
lumen of the intestine were found in small cysts beneath the 
intestinal mucosa. Recently he (Dr. Sambon) had bad the 
opportunity of investigating the life-history of a heterakis 
of the pheasant. Here again the parasite appeared in small 
cysts beneath the mucous membrane before entering the ca;cal 
cavities. Many other examples were given by Dr. Sambon, 
some of them observed by himself, as, for instance, in the case 
of porocephalus armillatus. Lastly, he spoke of the agency 
of metazoan parasites in the conveyance and development of 
secondary infections. Already in 1903 and 1905 at meetings 
of the British Medical Association he had pointed out that 
probably entozoa within the alimentary canal or within the 
tissues performed a role similar to that of blood sucking 
artbropoda from without conveying more minute pathogenic 
organisms from one anatomical habitat to another. Already 
Metchnikoff in 1901 had suggested that intestinal parasites 
might inoculate pathogenic organisms through the Intestinal 
mucosa and thus give rise to infectious diseases. Guiart, 
Blanchard, and others had recently maintained that 
appendicitis might be brought about by the agency of 
intestinal worms, and more especially the whipworm. Guiart 
had even suggested that typhoid fever and cholera might 
be favoured by the agency of whipworms, tapeworms, 
and other intestinal parasites. Finally, Weinberg had just 
published a most suggestive article on the subject in the 
Annales de Vlnstitut Patteur. So far they had little positive 
information in favour of the agency of entozoa with regard 
to the transmission of secondary infections, but on considera¬ 
tion the Bubject was pregnant with possibilities, and he 
believed the day was not far off when they would have 
experimental proof of the truth of this theory. In any 
case, whether harmful in themselves or on account of 
possible complications, the prophylaxis of the entozoan 
parasites of man imposed itself most urgently. In order 
to be able to prevent infection they needed to encourage 
and to further in every possible way the study of helmin¬ 

104 The Lancet,] 


[Jan. 11, 190a 


lagliocotian Skin-grafting of the Arm .— Ununited Fracturet 
Treated by Bone-grafting .— Tabetic or Trophic Foot .— 
Physiijue and Health in the Liverpool Sohoolt. 

A meeting of this society was held on Dec. 19th, 1907, 
Mr. Frank T. Paul, the President, being in the chair. 

Mr. G. P. Newholt showed lantern slides of a case 
operated upon by the Tagliocotian Method. The patient’s 
forearm had been severely injured in a railway accident, both 
bones being broken, the skin much lacerated, and the muscles 
and tendons partially torn away. A long flap of skin was 
raised from the abdomen below the left breast and the arm 
was passed under it so that it lay as if in a sling. As a result 
of this operation, which was completed in two further stages, 
the arm had been saved ; sensation was good and there was 
some movement in the Angers. The patient is still under 

Mr. RCSHTON Parker related two cases of Ununited 
Fracture treated by clearing out unossified tissue from between 
the fragments and planting in the interval small pieces of 
bone clipped from the seat of fracture. One case was that 
of a man, aged 35 years, whose left humerus had been 
broken six months previously and imperfectly united by 
incomplete callus, permitting movement and unfitting the 
limb for use. Union resulted in six weeks. The other case 
was that of a woman, aged 48 years, with total non-union of 
the left ulna of eight months' standing. There was pain as 
well as weakness and flexibility at the Beat of fracture. 
Union was still absent in six weeks but after hammering 
the seat of fracture it resulted firmly a week later. 
The practice was based upon the principle laid down 
bj Sir W. Macewen in his celebrated case. 1 —The Presi¬ 
dent said that he quite accepted the truth of Sir W. 
Macewen’s observations on which Mr. Parker had based his 
treatment of these interesting cases, but he did not consider 
that these observations contained the whole truth in refer¬ 
ence to the development of bone. If so, how were they to 
explain the formation of bone in various tissues, such as 
arteries, where no bone cells had ever existed 1 The constant 
precursor in such cases was a calcareous degeneration. If 
this excited any inflammatory change the young connective 
tissue formed bone. Calcified arteries, cysts, tumours, 4cc., 
in this way frequently originated bone in the neighbourhood 
of the calcareous deposit, and he would suggest that Mr. 
Parker should try the effect of the presence of phosphate of 
lime alone, as this could be introduced without a regular 

Mr. T. 0. Litler Jones showed a patient both of whose 
feet he had amputated on account of the condition known 
as Tabetic or Trophic Foot. Lantern slides were shown of 
x ray photographs of the feet at various Btages of the disease, 
exhibiting very clearly the progressive melting away of the 
phalanges without primary inflammatory changes. The 
patient had none of the ordinary symptoms of tabes dorsalis, 
appeared to be in excellent health, and could walk remark¬ 
ably well on his artificial feet. 

Mr. A. S. Arkle read a paper on Physique and Health in 
the Liverpool Schools based on his examination of children 
from schools of three classes under the control of the 
county borough education committee and the boys of a 
public school. The statistics showed clearly that there was a 
close relation between status in life and feeding and the growth 
and development of the children. The influence of feed¬ 
ing was shown by comparing the children of industrial schools 
with those of the lower class of council schools. In regard to 
health, attention was drawn particularly to heart lesions and 
abnormality of the eye, ear, nose, throat, and teeth.—Professor 
T. R. Glynn said that some of the facts demonstrated by 
Mr. Arkle's figures might have been anticipated, but others, 
as the small number of congenitally syphilitic children, were 
contrary to what might have been looked for ; the explanation 
was in some degree the early death of the infected children. 
He hoped that Mr. Arkle would have an opportunity of extend¬ 
ing his observations in other directions, such as the relative 
prevalence of hereditary degeneration.—Dr. E. W. Hope 
mentioned that the excellent work which had been done by 
Mr. Arkle during the last few years gave some indication of 

1 Reported to the Royal Society in 1881, repealed and amplified in 
his lecture at the University of Liverpool in December, 1906, again 
related to the Royal Society in January, 190'/, nuid published in the 
Proceedings of June and in the British Medical Journal of June 22nd, 

the magnitude of the task of the medical inspection of school 
children. It was absolutely necessary, as the excellent 
Memorandum of the Board of Education pointed out, to follow 
np the examination by an extension of the amelioration of 
the sanitary condition which had already proved so powerful 
a factor in improving the health of children. The methods 
of carrying out the Act had not been decided upon and Dr. 
Hope expressed the belief that the views of the medical pro¬ 
fession, if focussed and brought to the notice of the education 
authority, would receive every consideration at the hands of 
that body. He regarded the medical inspection of school 
children as an extremely important accessory in public 
health administration.—Mr. J. Bark agreed with Dr. Hope 
that the object of the Education Department was to prevent 
the occurrence in children of certain diseases which were 
detrimental to their physical and intellectual future. In the 
case of adenoids the earlier the removal was undertaken the 
better. The best results were obtained in children operated 
on between the ages of two and seven years. 90 per cent, 
of young children with enlarged faucial tonsils had adenoids. 
If the new Act was carried out efficiently the future genera¬ 
tions would be freer from deafness and chest troubles than 
the present. Dental examination and treatment were most 
important; oral sepsis was responsible for much of the 
physical deterioration of the race.—Dr. A. C. Wilson, 
medical officer to the truant schools at Hightown, said that 
he agreed with Mr. Arkle that under-feeding was the great 
cause of bad physique in the poorer classes of children. He 
rarely met with congenital syphilis, and this he attributed 
to the infected children dying out or getting into special 
institutions for the deaf and dumb, blind, or imbecile, Soc. 
The most pressing reform needed was the better care of the 
teeth. He was glad to say that the Liverpool education 
committee had recently appointed a dentist for all Liverpool 
schools. He believed that defective vision in children was 
to some extent due to the eye not being trained to distances. 
—Several other members having spoken. Professor Gi.yNN 
proposed, and Dr. G. G. Stopford Tayi.or seconded, the 
appointment of a subcommittee of the institution to consider 
and report on the Memorandum of the Board of Education. 
This proposal was adopted and a subcommittee was elected. 


Exhibition of Cases. 

A meeting of this society was held on Dec. 20th, 1907, 
Dr. J. Allan being in the chair. 

Mr. B. G. A. Moynihan showed a case of Complete 
Gastrectomy. The patient was a man, aged 43 years, with a 
two and a half years’ history. At the operation, on May 31st, 
1907, a condition of “leather-bottle” stomach was disclosed. 
The whole stomach was removed, the jejunum being joined 
to the oesophagus. The patient now ate well, worked as 
before, and had gained 3 stones in weight. 1 

Mr. Moynihan, with Dr. T. W t ari>rop Griffith, exhibited 
a case of Gastro-enterostomy for Pyloric Stenosis following 
corrosive poisoning. The patient swallowed half a pint of 
“spirits of 6altB.” At the operation the pyloric antrum was 
found to be almost solid. Gastro-enterostomy combined with 
jejunostomy was performed. 

Dr. A. G. Barrs, with Mr. J. F. Dobson, showed a case of 
Sub-diaphragmatic Abscess and Empyema rupturing through 
the Lung, apparently following a duodenal perforated ulcer. 
Drainage of the abscess and empyema by separate operations 
was followed by recovery. . 

Dr. T. Ciiurton showed: 1. A ca9e of Acute Spinal 
Myelitis in a boy, aged nine years. There were absolute 
paralysis and anfesthesia of the legs and incoordination of 
the detrusor and sphincter muscles in micturition. On 
July 13th he fell on his back ; in August the first symptom 
was difficulty in micturition. On the 17th signs of total 
transverse myelitis showed themselves. 2. A man, aged 57 
years, with Heart Disease and Anuria. Theocine sodium 
acetate, one grain every six hours, with strophanthin, ,Jothot 
a grain, had caused a great increase in the quantity of urine. 
In two former cases five-grain doses had been used ; the 
patients both got worse. 3. A girl, aged seven years, wit 
Partial Anuria and old Mitral Disease. Half a grain or 

1 Bee The Lancet, Dec. 21st, 1907, p. 1748. 

The Lancet,] 


[Jan. 11,1908. 105 

theocine every eight hoars with digitalis were administered 
and the urine became doubled in quantity. 

;Mr. La WORD Knaggs showed; 1. A case of Actino¬ 
mycosis of the Jaw after two scraping operations. The 
patient had been accustomed to drive a cart laden with 
grain and whilst doing so to chew some of the grain. At 
Christmas he pulled out one of his teeth and afterwards 
grams would lodge in the wound and the latter did not heal. 
Soon after the disease made its appearance. 2. A case of 
Stone in the Left Ureter of 11 years’ history, with removal. 
A median laparotomy was performed in October, 1907. The 
ureter was dilated and the kidney was hydronephrotic. The 
stone was pushed up from the pelvis to the loin. The ureter 
was then exposed through an incision in the posterior 
peritoneum and the stone was steadied by two strips of gauze 
slung round the ureter above and below it. In this way the 
ureter was temporarily occluded above and below and when the 
stone was expressed through a longitudinal incision no urine 
escaped. The wound in the ureter was closed with fine silk 
sutures a la Lembert and a drainage tube was passed through 
the left loin. The peritoneum was then closed over the 
ureter and the abdominal incision was sutured in the ordinary 
way. Recovery was without incident. 3. A case of Extro¬ 
version of the Bladder; Hysterectomy ; Peter’s Operation. 
The patient was a woman, aged 31 years. At four years of age 
she had had Wood's (!) operation performed by Mr. W. H. H. 
Jessop. The result had been satisfactory, the bladder wall 
being covered over. Her condition, however, as she grew up 
became one of great misery, the vulva being kept in a 
constant state of irritation and inflammation as a result of 
the dribbling of urine and the deposit of phosphates on the 
hair and within the cul-de-sac which had been formed by 
operation. Her sufferings were aggravated at the periods 
and on inspection the condition of the parts was very foul. 
On June 26th, 1907, an operation was proceeded with 
and six weeks later a second one was performed. The parts 
were now clean, there was no offensive odour, and the urine 
was retained for four, and sometimes for five, hours. There 
was a small leak from a deep pocket in the original wound 
area, but she kept herself quite comfortable by a small pad 
which she changed two or three times a day. 

Dr. J. Gordon Sharp exhibited a case of Vaso motor 
Neurosis with Dermographism in an undersized boy, 14 
years of age. The patient had always a diffused blush over 
his face, which became accentuated by excitement and by 
stimulation of the skin. When any part of the skin of the 
body was written upon by a blunt instrument there followed 
in a few seconds a deep blush, and in a few seconds later 
the writing appeared as a white wheal, and remained 
for some time. The pulse-rate was now about 100. A 
thrill was ielt in the mitral area, and in the same region 
presystolic and systolic murmurs were heard but conducted 
to other areas. 

Dr. Barrs and Mr. H. Littlewood showed a case of 
Paraplegia with Sarcoma of the Spinal Meninges, in which 
laminectomy and removal of the growth were performed, 
recovery ensuing. The patient had for six months suffered 
from pain in the back at the level of the tenth dorsal spine, 
with stiffness and numbness of the right leg. There bad 
been a rapid increase of symptoms. On admission to hos¬ 
pital there were found to be complete paraplegia with 
anaesthesia up to two inches above the umbilicus and a 
narrow zone of hyperesthesia above this. Laminectomy 
was carried out and the tumour was removed. The patient 
had been shown to the society before but at that time he 
could only move his legs, whereas now he could walk. 

Mr. Littlewood showed : 1. A case of Carcinoma of the 
Rectum and Splenic Flexure in a patient, aged 52 years. 
Colotomy was performed on Nov. 8th, 1906, but with no 
relief. On Nov. 14th the abdomen was opened in the middle 
line and a mass was found in the splenic flexure. A Paul’s 
tube was put into the csecum. On Dec. 6th an enterectomy 
was carried out and on Jan. 10th, 1907, proctectomy was per¬ 
formed. 2. A case of Carcinoma of the Rectum and Ascend¬ 
ing Colon in a patient, aged 69 years, in which a polypoid 
malignant mass was found. On August 22nd, 1907, proct¬ 
ectomy was performed. The patient had symptoms of 
obstruction three months later and a mass was found in the 
ascending colon with nodules in the liver. On Nor. 14th a 
lateral anastomosis of the small intestine with the transverse 
colon was carried out and great relief followed, 3. A case 
of Pigmented Lymphangioma of the Foot in a patient aged 
14 years. 

Mr. W. Thompson showed a case of Actinomycosis of 

the Cheek and the Glands of the Neok. 18 weeks previously 
a swelling bad appeared in the mouth which had burst 
externally. The patient bad been in the habit of eating a 
little corn when feeding his pigeons. 

Dr. A. Wear showed: 1. Erythema Induratum Scrofulo- 
sorum in a patient, aged 36 years. The first appearance of 
the disease had occurred ten years previously, both legs 
being affected simultaneously, and repeated attacks had since 
been experienced. 2. Adenoma Sebaceum. The tumours 
were situated on either side of the nose. 

Mr. L. A. Rowdex and Dr. W. H. Maxwell Telling 
exhibited a case of Chronic Favus of Six Years’ Duration in 
a Child Treated by X Rays. Only a siDgle exposure was given 
on each affected area. 

Dr. Telling showed : 1. A case of Congenital Hypotonia 
(or amyopla-ia) in an infant, aged one year and nine months. 
Since birth the hands and feet had been noticed to be very 
soft ; these especially, and the limbs and skeletal muscles 
generally, were markedly flaccid and toneless, allowing 
considerable bending at the joints. The patient had been 
under continuous observation for 15 months with no notable 
change in the muscular condition. 2. Subacute Tylosis of 
the Nail-matrix. The condition bad commenced about three 
and a half months previously in one finger and rapidly 
spread to all the other fingers. There was a dry warty over¬ 
growth at the distal margin of the nail-bed which was 
lifting up the nail and spreading to the root in a V-shaped 

Dr. E. F. Trevelyan showed : 1. Five cases of Peripheral 
Birth-palsy, illustrating lesions of the brachial plexus. 
2. Brown-Sfiquard Paralysis in a woman, aged 47 years, who 
had been stabbed in the back in August, 1907. On Oct. 4th 
a scar was seen in the neck to the right of the third cervical 
spine. There were motor paresis of the right arm and 
paralysis of the right leg and a considerable sensory loss on 
the left side. The patient was improving. 

Dr. Alexander Sharp showed a case of Fibroma of the 

Mr. A. L. Whitehead exhibited a case of Congenital 
Left-sided Ptosis treated by Plastic Operation. 

Mr. Michael A. Teale showed : 1. A case of Staining of 
the Cornea of the Right Eye following an extensive haimor- 
rhage into the anterior chamber. 2. A boy showing a Con¬ 
genital Coloboma of the Right Iris directed upwards and 

Cases were also shown by Dr. A. Bisonner, Mr. H. Secker 
Walker, and Mr. Alexander Smith. 


Exhibition of Cages. 

A meeting of this society was held on Dec. 18th, 1907, 
Dr. James Ritchie, the President, being in the chair. 

Dr. Alexander Bruce showed the following patients. 
1. A woman suffering from Myasthenia Gravis. She became 
fatigued on the slightest exertion and after climbing a stair 
she was completely collapsed. No muscular atrophy was 
present and there was no reaction of degeneration in the 
muscles, but the myasthenic reaction to electricity was 
present—i.e., the muscle soon ceased to respond to elec¬ 
trical stimulation. 2. A woman suffering from Amyo¬ 
trophic Lateral Sclerosis. This was essentially progres¬ 
sive muscular atrophy along with lateral sclerosis. The 
patient also showed bulbar phenomena. The condition 
had lasted barely two years. Atrophy of the left hand 
and arm was marked, the right extremity not being so 
advanced. The facies was peculiar, the lips were tightly 
compressed, and there was difficulty in protrnding the tongue. 
3. A woman exhibiting Neuritis of the Left Median Nerve. 
She had pricked her hand with a needle last July and 
subsequently a diffuse cellulitis of the front and back of the 
hand developed with pain along the course of the median 
nerve which was followed by desquamation of the skin in 
this area. At present there was tenderness over the whole 
of the left arm with tactile anesthesia over the whole 
area of distribution of the nerve, while marked hyper¬ 
algesia was present over this area. There was involve¬ 
ment of the roots of nerves of the cervical plexus 
and this extended as far down as the fourth dorsal 
nerve. The muscles of the left shoulder were atrophied. 

106 The Lancet,] 


[Jan. 11, 1908. 

4. A woman who easily became very emotional and this was 
associated with a Clonic Spasm of the Right Hand. The 
right eyeball was prominent and the right side of the face 
was also enlarged. When she cried tears flowed most 
abundantly from the right eye and she also perspired more 
freely on this side of the face. The right side of the thyroid 
gland was somewhat enlarged. The condition was con¬ 
sequent on removal of both ovaries on account of double 
ovaritis. 5. A man who suffered from the rare spasmodic 
form of Syringomyelia. In February, 1907, he had an attack 
of numbness of the left arm and suddenly the Eecond and 
third fingers became flexed firmly on the palm and since then 
they could not be extended. The wrist, the elbow, and the 
shoulder-joint were also fixed. Over the left shoulder there 
was a large swelling and the whole tissues on the left side of 
the thorax were tough and firm as compared with those 
on the right side. There was loss of sensibility to heat and 
cold along the inner side of the left forearm. 

Professor John Chiene said that he was not satisfied 
with any of the methods of treating Congenital Wryneck. 
In a recent case he had operated by tumiDg down a flap of 
skin and tissue on the side of the contracted muscle over the 
mastoid ; he had then stripped off the periosteum from the 
mastoid process and so freed the upper end of the 
sterno-mastoid muscle. He had attached the upper extremity 
of the detached periosteum to the apex of the mastoid process 
and had thus elongated the muscle on the shortened side. 
The result had been excellent. He demonstrated the case 
of a young man who had been incapacitated for work by 
reason of a loose body in his left elbow joint which caused 
the joint to lock. The operation consisted in turning down 
a flap of skin from the back of the elbow above the joint and 
splitting the triceps after which an excellent view of the 
interior of the joint was obtained and a large loose body was 

Mr. F. M. Caird exhibited eight cases in which Pylor- 
ectomy had been performed for malignant disease and in 
which the patients survived in perfect health. Healso showed 
a woman, aged 27 years, who had made a good recovery after 
an operation for Acnte Pancreatitis. She bad been seized 
with acnte epigastric pain, vomiting, and catchy respiration. 
The pupils were remarkably contracted and a diagnosis of 
acute pancreatitis was made. On opening the abdomen 
bloody serum exuded and on the surface of the omentum 
white spots of fat necrosis were observed. On the pancreas 
two large necrotic areas were observed ; these were scraped 
and drained. The gall-bladder was greatly enlarged and was 
stitched to the abdominal wound. When it was opened much 
dark bile and numerous gall-stones escaped. 

Dr. R. W. Philip showed several patients illustrative of 
the Cutaneous and Ophthalmic Tuberculin Reaction. He 
said that iu suspicious and not easily recognised cases of 
tuberculosis this reaction might be useful. For some years 
past he had employed the subcutaneous injection of tuber¬ 
culin as a diagnostic aid and stated that it was accompanied 
by no serious risk. It had been condemned, however, as 
likely to induce an acnte exacerbation in latent tuberculous 
conditions. He showed cases in illustration of the cutaneous 
method. The skin c f the arm was scarified in the ordinary 
manner and a solu ion of tuberculin was rubbed in. This 
solution contained 25 per cent, solution of old tuberculin. 
25 per cent, solution of carbolic acid in glycerine, and 50 
per cent, of normal saline solution. In the course of from 
24 to 48 hours a definite local reaction in the form of a rosy 
red patch was seen, the skin became infiltrated, and papules 
or vesicles formed. A scaly condition of the skin followed 
and the redness faded, but for some weeks subsequently a 
certain degree of pigmentation remained. The ophthalmic 
reaction was obtained by dropping one minim of the 
following solution between the eyelids. In from 
three to six hours later a perfect reaction was ob¬ 
tained and left no permanent change. The solution 
consisted of five milligrammes of dry tuberculin (preci¬ 
pitated by alcohol) in ten minims of sterile normal saline 
solution. A congestion appeared on the palpebral and ocular 
conjunctiva, especially towards the inner canthus. The 
caruncle became inflamed and a certain amount of exudate 
might form. The reaction seldom persisted for more than a 
week. It had to be borne in mind that the reaction might 
not occur even in cases in which tubercle bacilli might be 
abundantly observed. 

Mr. H. Alexis Thomson showed a patient, aged 29 years, 
who had sustained a Gunshot Injury of the Upper Arm six 
months before he came under observation, with smashing of 

the humerus and tearing of the mnsculo-spiral nerve. An 
operation was performed for ununited fracture of the 
humerus, when it was found that the extent of destruction 
of the nerve rendered suture impossible. The distal end was 
therefore inserted into the median nerve above the elbow. 

Mr. J. W. B. Hodsdon showed a case of Dupuytren’s Con¬ 
traction which had persisted for 20 years and was cured by 
hypodermic injections of “ fibrolysin.” Two cubic centi¬ 
metres of the solution bad been injected on 19 occasions, 
either intravenously or subcutaneously, and not necessarily 
near the affected part. Fituolysin caused a softening of 
pathological fibrous tissue, but as it did not cause its absorp¬ 
tion this had to be facilitated by massage, Ac. This treat¬ 
ment was useful in all cases of fibrous adhesions, scars, 
adhesions of the pelvic organs, corneal opacities, Ac. 

Mr. E. W. Scott Carmichael showed a boy, aged ten 
years, after Acute Suppurative Cholangitis and Cholecystitis 
following generalised streptococcal peritonitis. 


Section of Obstetrics. 

Exhibition of Speciment .— The Teaching of Obstetrioe. 

A meeting of this section was held on Dec. 13th, 1907, 
Mr. E. H. Tweedy, the President, being in the chair. 

Dr. Henry Jellett exhibited a Uterus showing unusual 
tliinniDg of the muscle of the fundus after pregnancy 
obtained from a patient who was 30 years old and was 
suffering from carcinoma of the vagina. She had had a baby 
four weeks before going into hospital. He decided to 
perform an operation but during the night before it was to 
take place her temperature rose to 104° F. and she had 
severe rigors. On the morning of the day of the operation 
her temperature was still 104° and her pulse-rate anything 
up to 140. The operation was therefore contra-indicated 
and so he thought it best to wash out the uterus. Before 
doing so he inserted a sound and this passed into the abdo¬ 
minal cavity straight through the fnndns the resistance of 
which was quite inappreciable. He did not like to leave a 
probably septic uterus with an opening into the peritoneum 
and so he removed the uterus by the vagina and as much of 
the cancerous vaginal wall as he could. After the operation 
be split the uterus to see why the sound had gone through it 
and he found that there was a cone-shaped excavation 
extending through the fundus almost up to the peritoneum. 
The rest of the wall preserved its normal thickness. Micro¬ 
scopical examination of the fundus showed no evidence of 
malignant growth. The only explanation that he could offer as 
to the cause of the perforation was that the placenta had 
exercised an eroding influence on the uteruB at one spot. 
The patient got better for a time but died about two months 
afterwards from general metastases and weakness. 

The President exhibited a Double Pyosalpinx removed 
intact. He said that the patient complained only of sterility. 
She had no pain and she did not look ill. She was young, 
two or three years married, and had been sent to him to be 
curetted. He palpated the tumours and diagnosed double 
ovarian cyst; the uterus was felt lying between them. He 
was very much surprised to find that they were really very 
large tubes. They were taken out and joined together 
without difficulty. The point of interest was that he hoped 
he had thus cured the patient's sterility. There was one 
ovarian cyst which was removed. The other ovary was 
resected and a good sound piece left behind together with 
healthy tube stumps. 

Sir William J. Smyly opened a discussion on the Changes 
which had been suggested by the General Medical Connell 
in the method of Teaching Practiced Obstetrics. He said 
that the circumstances which had led up to the action of the 
General Medical Council originated in the discovery of the 
true nature of puerperal fever by Semmelweis and its pre¬ 
vention by Lord Lister, in consequence of which this scourge 
bad been practically banished from our lying-in hospitals- 
The hope that a similar result would follow in general 
practice had not been realised, and Dr. R. Boxall had shown 
that from the returns of the Registrar-General it appeared 
that the maternal mortality from septic infections in child¬ 
bed was even worse than it had been. The pnblio'tion of 
these facts produced a profound impression in England, the 
outcome of which had been the Midwives Act and the eno » 

Thi Lancet, ] 


[Jan. 11,1908. 107 

on the part of the General Medical Conncil to improve the 
education of students in midwifery. In England the oppor¬ 
tunities for the teaching of practical midwifery were meagre 
so that it was necessary to make very moderate demands 
upon students with regard to the practical study of mid¬ 
wifery, but in Ireland, with its great lying-in hospitals, 
it would be a retrogression to adopt any of the recommenda¬ 
tions of the General Medical Council. Dr. Boxall had shown 
that the statistics of obstetrics in general practice were 
worse in Ireland than in England. In order to remedy this 
students must either be compelled to attend a certain number 
of confinements or demonstrations, or, what would be much 
better, a desire to study practical obstetrics must be aroused 
in them by adopting the recommendation of the General 
Medical Council with regard to practical clinical examination. 
They should be made to feel that a practical knowledge of 
obstetrics and gynaecology was useful in passing examinations. 
—Mr. A. J. Horne said that the subject was of particular 
interest to Dublin, which was practically the home of 
obstetrics. The Dublin school for a great number of years 
had rightly insisted that the course of study should be a 
comparatively long one, and the General Medical Council, in 
order to raise the standard of both England and Scotland, 
had offered to compromise with Dublin by suggesting that 
the period of study should be three months. Annually in 
Dublin something like 200 students had to take out their 
course of midwifery. If they simply attended for three 
months it would be utterly impossible to supply them 
with material for each man to take out his 20 “con¬ 
ductions.” The period was too short. How it would 
be accomplished in England he did not know, but 
he did not believe that the keeping up of the existing Dublin 
standard would cause a single pupil to leave the country.— 
Dr. Frederic W. Kidd said that midwifery was a subject 
in which it was very necessary to have a thorough knowledge 
of the theory before practical work was attempted. It was 
an established fact that the mortality in the lying-in hospitals 
was lower than that of general practice in the country, not¬ 
withstanding that the dangers to a woman in a hospital were 
greater than those in private practice and the cases were 
more morbid and serious. The unavoidable inference was 
that the medical practitioners and nurses did not carry out 
in general practice the same strict rules of asepsis as in the 
institutions where they were taught to do so. He felt that 
a man who lived in the precincts of a hospital for one 
month would in all probability lay up a greater store 
of knowledge than one who attended a lying-in hospital 
two days in the week for three months.—Dr. Richard D. 
Purbfoy suggested that some arrangement might be made 
with the masters of the hospitals by which the obstetrical 
examiners of the colleges might make a monthly visit snd 
have opportunity given to examine certain students. This 
would obviate the difficulty of carrying out the practical 
examination for a large number of students at one time. 
He thought that students should be encouraged to reside 
even for one month, in some of the maternity hospitals.— 
Dr. Jei.lbtt said that they were all probably agreed 
that the recommendations of the General Medical Council 
were extremely good, with the exception of the altera- 
tion in the course of attendance at maternity hospitals 
from six to three months. In Ireland such an altera¬ 
tion would shorten the present course, whereas in England 
and Scotland it would raise it to a much higher standard 
than before. He was quite aware that the present state 
of affairs was open to the objection that all students did 
not attend the full course. A three months’ course pre¬ 
sented the great practical difficulty that students could not 
1 m given their 20 cases in so short a time. He thought that 
if the Dublin Colleges adhered to their six months’ course 
and made some attempt to define regular attendance they 
would not only maintain but enhance the reputation of the 
Dublin School and would make the obstetrical train¬ 
ing of the greatest value to the student,—Dr. Robert J. 
Rowlbtte said that there were certain faults in the 
final examinations in midwifery and gynaecology and that 
if these were taken away the subjects would be more 
attractive to students : one was the excessive amount of 
surgery required by the gynecological examiner ; it vas ro 
part of the duty of an ordinary medical practitioner to be 
able to perform highly technical operations. If the student 
was going to be a specialist he must make up his work afler 
his qualifying examination, not before it. He was only 
referring to highly technical operations; operations of 
emergency must, of course, be within the knowledge of every 

medical man. As to the high mortality in private practice he 
thought it might be explained by the fact that more cases of 
childbirth were left unattended by medical men in Ireland 
than in England. It was also quite impossible for a medical 
man to practise the same aseptic precautions in a country 
cottage as in a hospital.—The President said that it was 
pleasant to see with what unanimity the members of the 
Obstetrical Section opposed the suggested curtailment of the 
period at present deemed necessary in Dublin for attendance 
at maternity hospitals —It was then proposed by Sir William 
Smyly, seconded by Dr. Jelleit, and carried unani¬ 
mously :— 

That the Obstetrical Section of the Academy of Medicine regRrdB the 
recommendations of the General Medical Council regarding obstetrical 
teaching as in many rases a very great advance on the present con¬ 
ditions. The section, however, considers that the suggested alteration 
of the period of attendance on a maternity hospital from six months 
would not be advisable or practicable. The section considers that 
instead of reducing tlie attendance the licensing bodies should adopt 
such regulations as will insure regular attendance of students at the 
clinical teaching of the hospitals. With regard to the adoption of a 
practical examination in midwifery and gynaecology, the section con¬ 
siders that such a step is most desirable and urges ita members to aid it 
by all means in their power. 

Dr. Purefoy then proposed, Dr. Kidd seconded, and it 
was carried unanimously :— 

That a committee consisting of the masters and assistants fpast and 
present) of the Dublin maternity hospitals be appointed for the purpose 
of urging upon the licensing bodies the inadvisability of changing the 
course of practical obstetrics from six months to three months. 

Windsor and District Medical Society.—A 
meeting of this society was held at the Guildhall, Windsor, on 
Dec. 18th, 1907, Dr. E. S. Norris (Eton), Vice-President, 
being in the chair.—Dr. W. H. W. Attlee read a paper 
entitled, “ The Treatment of Puerperal Eclampsia.” He com¬ 
menced by recounting the theories advanced to explain the 
phenomena of eclampsia, the microblc, the placental, that 
of thyroid inadequacy, and the auto-intoxication theory, 
pointing out that the last was the one which found most 
favour at the present day, the toxin being supposed to be 
formed in some way in the intestinal tract and absorbed 
from there into the general circulation. This was 
borne out by post-mortem appearances, for the cell 
necrosis so evident in the abdominal viscera was 
most noticeable in the liver, which was what would 
be expected if the portal vein were collecting the poison 
from its tributaries. Dr. Attlee proceeed to divide 
the treatment into two stages : (1) that before the con¬ 
vulsions bad occurred ; and (2) the actual attack of 
eclampsia— i.e., when the convulsions had begun. In the 
first stage he advised the postponement of active measures 
as long as possible, treating the patient with rest in bed, 
absolute quiet, free purgation with calomel or diuretic salts, 
and a milk diet, if in spite of this matters grew worse 
labour would have to be induced. In this connexion Dr. 
Attlee emphasised the importance of examining the urine of 
every pregnant woman and related a case illustrating the 
benefit derived from such routine examination. When the 
fits had already begun the first duty was to attend to the 
convulsions. The patient should be prevented from injuring 
herself and the tongue should be protected. One minim of 
croton oil or five grains of calomel or even salts if possible 
should be administered at once. Chloroform should be 
used to control the paroxysms, and when the patient was 
well under its influence an examination should be made 
and a decision arrived at as to whether labour should be 
terminated or not. With regard to this important point 
Dr. Attlee said that probably the indications for induction of 
labour were similar to those which would point to a grave 
prognosis—viz., fast and feeble pulse, scanty urine, rising 
temperature, and a prolonged duration of coma between the 
fits. The scantiness of the urine was more important than 
the amount of albumin. After describing the best means of 
inducing labour Dr. Attlee detailed the treatment to be 
adopted if it should be decided not to terminate the labour. 
In this event he said that morphine should be given, best 
hypodermically in doses of one-third of a grain every 
two hours until a grain had been given. Saline 
solntion should also be infused both into the subcutaneous 
tissues and into the rectum. The administration of thyroid 
extract was discussed. Should the eclampsia occur 
actually during labour Dr. Attlee advised that the labour 
should be terminated as quickly as possible, great care being 
taken to avoid sepsis, the danger of this complication in 
such cases being duly insisted on. Allusion was made to the 

108 The Lancet,] 


[Jan. 11,1908. 

post-partum variety of eclampsia, and here again it was 
said that the drag indicated was morphine. Finally, 
Dr. Attlee read notes of a most unusual case, fortu¬ 
nately with a favourable termination, in which the 
puerperium was complicated by symptoms of the gravest 
augury—viz., jaundice, suppression of urine, twitching 
of the limbs, drowsiness, and coma. There were diminution 
of the area of liver dulness and tenderness over the right 
hypochondrium, the temperature and pulse being only very 
slightly raised. The rapidity with which these symptoms 
disappeared suggested some form of toxaemia as the cause, 
but whether this was of the nature of eclampsia, Icterus 
gravis, or saprtemia he was unable to determine.—A brief 
discussion ensued in which Dr. Norris, Dr. W. F. Lloyd, Mr. 
J. W. Gooch, Dr. A. M. Amsler, Mr. A. D. Crofts, and Dr. 
C. R. Elgood took part. 

Jekietos aito State of Jacks. 

Surgery, its Principles and Practice, By Various Authors. 
Edited by William Williams Keen, M.D., LL.D., 
Professor of the Principles of Surgery and of Clinical 
Surgery, Jefferson Medical College, Philadelphia. Vol. I., 
pp. 983. With 261 text illustrations and 17 coloured 
plates. London and Philadelphia : W. B. Saunders Com¬ 
pany. 1906. Price 30». 

Professor Keen has secured the assistance of 66 able 
colleagues in the arduous work of compiling a system of 
surgery. It is to extend to five volumes and will contain 
more than 4000 pages, and the names of the writers are in 
themselves a guarantee that this treatise will contain a full 
exposition of modern surgery. No one could be better fitted 
for the task of editing such a work as this than Professor 
Keen and a careful perusal of this volume serves but to 
confirm our anticipations. Dr. Mumford of Boston has con¬ 
tributed a sketch of the History of Surgery and though by 
no means exhaustive it is sufficiently full for a text-book. 
Unfortunately, few surgeons seem to care about the history 
of their craft. It has often been suggested that the history 
of medicine should be a subject for examination ; this is not 
desirable, as the curriculum is quite extensive enough at 
present; but at most medical schools a few lectures each 
year on the history of the medical sciences would, we are 
sure, be well attended and very popular. The University of 
London might well consider the question of instituting some 
such lectures. Dr. G. W. Crile of Cleveland has contributed 
a chapter on Surgical Physiology. It deals chiefly with the 
changes of blood pressure in injuries and operations. It is of 
very definite interest and importance. The article on the 
Examination of Blood by Dr. J. C. Da Costa, jun., is mode¬ 
rate in tone and does not claim for examinations of blood that 
finality in doubtful cases which some of the advocates of 
bsematology demand for it. In many difficult cases the 
surgeon needs all the aid that can be obtained and exa¬ 
mination of the blood may assist in deciding on a diagnosis, 
but like most other signs and symptoms it must not be given 
pathognomonic value. Dr. Ludvig Hektoen of Chicago has 
written a useful chapter on Infection and Immunity and he 
has explained fully the various current theories of the latter 

The chapter on Inflammation has been contributed by Dr. 
J. G. Adami of Montreal and it is hardly necessary to say 
that the account is thoroughly good. The part of the article 
dealing with the treatment of inflammation has to do only 
with the broad questions of treatment, the details of the 
treatment of special inflammations being dealt with else¬ 
where. Dr. G. K. Armstrong has assisted Dr. Adami in 
some of the practical details and the result is excellent ; it 
is a happy combination of theory and practical knowledge. 
The treatment advised must depend, to a large extent, on 
our present knowledge of inflammation, but recognising, as 
we all mast, that that knowledge is not final the authors 

have wisely not carried the theories to extremes. They 
explain the arrest of erysipelas from painting the healthy 
skin beyond with nitrate of silver as due to a localised 
leucocytosis, and the frequent failures of this method of 
treatment are attributed to the painting having been done 
too near the advancing erysipelatous edge, for strepto¬ 
cocci may be as much as half an inch in front of the 
visible edge of the erysipelas. In similar ways the authors 
explain both the successes and the failures of many of our 
procedures which we have employed for empirical reasons 
for many years. 

Dr. L. Freeman of Denver is responsible for the section 
on Suppuration, Abscess, Ulceration, and Gangrene, and we 
need only say that it is very readable and up to date. Dr. 
F. C. Wood’s account of the process of repair is provided 
with a good bibliography, though, as the writer remarks, it 
contains only the more important references. Here we may 
mention that all the articles conclude with a list of the more 
valuable writings on the subject treated. Dr. C. H. Frazier 
of Philadelphia has written on Thrombosis and Embolism 
and the succeeding articles deal mainly with specific diseases, 
Dr. Frazier writing on Erysipelas, Tetanus, Anthrax, Actino¬ 
mycosis, and similar infections ; Dr. Frazier speaks in favour 
of intraneural injections of antitoxin in the treatment of 
tetanus—a method but little used in this country. 

Dr. E. A. Smith of Buffalo has contributed an excellent 
article on the Traumatic Fevers. He objects to the use of 
the term “ sapnemia," chiefly apparently because it is not 
always possible to distinguish between cases where the pro¬ 
ducts only of the micro-organism in the wound have been 
absorbed and those cases where the pathogenic organisms 
themselves have entered the blood stream. We cannot agree 
with him ; the distinction in typical cases is clear and im¬ 
portant and the term well deserves to be retained. The 
article is illustrated by some very good temperature charts. 
In Dr. E. H. Nichol’s paper on Rickets he discusses the 
etiology and he mentions the deficiency of lime theory, 
the lactic acid theory, and the toxic theory, but he does not 
(so far as we have been able to seel say anything about the 
theory that absence of assimilable fat in the food is the 
cause of rickets. The chapter on Surgical Tuberculosis by 
Dr. J. C. Da Costa occupies over 80 pages and gives a good 
account of this important branch of surgery. The tuberculin 
treatment is mentioned and condemned but nothing is 
said of the use of tuberculin when controlled by opsonic 
estimations. m 

Dr. E. Martin of Philadelphia has written on Chancroid 
and on Syphilis. We agree with him that the chancroid is 
probably caused by a special micro-organism and is not 
merely the result of ordinary pyogenic cocci. The 
spirochaita pallida is described and figured. The section 
on parasyphilis is poor. This grouping suggested by 
Fournier of a large number of indefinite conditions, many 
of which have absolutely nothing to do with syphilis, is 
decidedly a retrograde step. To include in one class leuco- 
derma, keloid, diabetes, and neurasthenia is absurd. Tabes 
and general paralysis of the insane stand upon quite a 
different footing. It is useless to finish this section by such 
a sentence as this: “Infantilism, hydrocephalus, hare-lip 
and cleft palate, olub-foot, idiocy, any of the dystrophies 
may be parasyphilitic in nature.” Mr. J. Bland-Suttons 
paper on Tumours is characterised by that originality of idea 
and method for which he is well known. It is very complete, 
occupying nearly 150 pages. Dr. Crile has written on Wounds 
and Contusions and also on Shock. He describes the "pneu- 
matiosuit” which he invented ; it consists of a double layer of 
rubber which is inflated with a bicycle pump. By means of 
this suit he can raise the blood pressure by from 15 to 40 
millimetres of mercury. It is certainly ingenious and 
deserves to be known more widely. 

The whole volume is very fully illustrated and we must 

Th* JjANCKT,] 


[Jan. 11, 1908. 109 

not omit to mention the extensive index which has been pro¬ 
vided. The work is a credit to the editor, to the contributors, 
and to the publishers. 

The Labyrinth of Animals. By Albert A. Gray, M.D. 

Glasg., F.R.S.Edin. Vol.I. London : J. and A. Churchill. 

1907. Pp. 198. Price 21s. 

This volume is the first instalment of a series of stereo¬ 
scopic plates illustrating the internal ear of animalB, by 
which we presume vertebrates are meant. The author decides 
—and we think wisely—to work downward through the verte¬ 
brate phylum, beginning with man ; consequently this first 
volume with its 31 plates deals with only a part of the 
mammalian class and includes the orders of Primates, 
Cheiroptera, Carnivora, Ungulata, Edentata, and the 
majority of the Rodentia. An examination of the plates 
shows that technical skill of the highest class must have 
been expended on the preparation of the specimens 
as well as in photographing them, and we are not 
surprised to read that the author has spent seven 
years in completing his series and that a large part 
of this time was devoted to perfecting his methods. Each 
plate shows the labyrinth decalcified and removed from 
the sknll, suspended by the superior semicircular canal and 
looked at generally from the outer side. A small stereo¬ 
scope is inclosed in a case in the cover of the book and with 
a very little practice a perfectly beautiful representation of 
the original specimens is seen magnified some five times. 
The method of preparation is fully detailed; roughly 
speaking, it consists in decalcifying and clearing but the 
minutiae are complicated and each specimen takes three 
months before it is ready for photographing. 

There is no donbt that this will prove a valuable work 
of reference for the comparative anatomist, the physiologist, 
and the aural surgeon. To the first certainly it is 
most valuable because up to the present so little has 
been known about the internal ear of mammals, although 
Retains has done much for that of the lower verte¬ 
brates. Dr. Gray regards the cochlea as a useful structure to 
take into account in the classification of animals, because, as 
he says, it is not subject to marked variation as a result of 
particular environment. Whether an animal lives in the air, 
the water, in the tree tops, or underground, it must always 
hear and so, if its cochlea varies, it is a sign of relationship 
rather than excessive use or disuse. We are a little doubtful 
whether the material at Dr. Gray’s disposal is sufficiently 
large to allow him, cot to dogmatise—he does not attempt 
that—but to make even plausible suggestions. It must be 
remembered that, immensely valuable though his contribu¬ 
tion to science is, it is only a contribution, and that 
generalisations on the bats have to be made on his two 
specimens, one of the fruit bat and the other of the pipis¬ 
trelle, while that extremely heterogeneous order, the Edentata, 
is also only represented by two specimens, the three-toed 
sloth and the Tamanduan ant-eater. Until more material is 
available it would be premature to say whether the cochlea 
is or it not a point of classificatory value. ' 

The author notices that cochleae fall into two categories 
which he calls flat and sharp pointed and that these are not 
necessarily dependent on the number of turns there is in 
the spiral. He further points out that the different orders 
of mammals fall moderately satisfactorily into one or other 
of these categories; but here again we should like more 
material before expressing an opinion since both types of 
cochlea have been found in the marsupials, although only 
the kangaroo, the wallaby, and the phalacger have been 
examined. A very interesting point in the semicircular 
canals is the variable size of the perilymph space which is in 
most mammals small or even absent, though sometimes, as in 
man, larger than the endolymph space. Dr. Gray thinks 

that the latter is probably the more primitive or generalised 
condition since it also exists in reptiles and birds. 

In discussing the subject of otoliths the author says that 
it is important not to mistake them for pathological deposits 
of calcareous salts which may occur in any animal and in 
any position in the vestibule. It is not quite clear whether 
these deposits are the otoconia which are well known to 
comparative anatomists and are so constantly found that it 
is doubtful whether pathological is quite the right adjective 
to use; indeed, there is one shark which accumnlates 
granules of sand through an open aqueductos vestibuli and 
these apparently serve the same purpose as the otoconia in 
other forms. 

At the end of the book is a table of measurements which 
will be undoubtedly valuable in the future when the morpho¬ 
logists, physiologists, and field naturalists come to tackle 
seriously the meaning of the variations found in the internal 
ear. Meanwhile, we cordially thank Dr. Gray for a valuable 
addition to our knowledge and look forward to the appear¬ 
ance of his second volume. 

Atlas and Epitome of Diseases of Children. By Dr. R. Hecker 
and Dr. J. Trumpp. Authorised translation from the 
German, edited by Isaac A. Abt, M.D. With 48 coloured 
plates and 147 black-and-white illustrations. London and 
Philadelphia : W. B. Sannders Company. 1907. Pp. 453. 
Price 21s. net. 

The original German work, of which the present volume is 
the authorised English translation, was published in the year 
1905. In Germany the book has proved an undoubted 
success owing probably to the fact that a work of this kind, 
attractive in appearance and profusely illustrated, presents 
a striking contrast to the usual ponderous and dull class of 
book which is published for the instruction of German 
students. The authors admit that no text-book can take the 
place of clinical observation but they believe that this 
failing can to a great extent be supplied by pictorial illustra¬ 
tion of the kind to be found in their atlas and epitome. With 
this object in view they have arranged an enormous number 
of coloured and uccoloured illustrations in a series and in a 
manner which they believe will be useful to students who 
have not had the advantage of complete clinical instruction. 

In the translation considerable changes have been made in 
the sections on therapeutics and these have been revised in 
accordance With accepted practice in America; additions 
made by the editor will be found inclosed in brackets. So 
far as the text is concerned there is little need for comment; 
it represents a highly condensed and commendably accurate 
summary of the common diseases and ailments to which 
children are subject. Therapeutics and treatment, in spite 
of the alterations and amendments made by the editor, are 
scanty and of such a superficial character that we doubt 
whether they will be of much use to the student or 
indeed to the practitioner. On the other hand, the illustra¬ 
tions, especially of the rashes of the specific fevers, should 
be extremely valuable ; there seems to us, however, to be 
far too many illustrations of microscopic and macroscopic 
pathological specimens. The illustration of Hecker’s urine 
vessel for infants which appears on p. 386 shows an infant 
placidly sucking an indiarubber teat. We hope that the 
students who read this book will not regard ‘ ‘ the comforter ’* 
as an essential in nursery equipment. 

An Index of Treatment by Various Writers. Edited by 
Robert Hutchison, M.D, Edin., F.R.C.P. Lond., 
Physician to the London Hospital, &c., ana H. 
Stansfield Collier, F.R.C.S. Eng., Surgeon to St. 
Mary’s Hospital, &c. Bristol: John Wright and Co. 
1907. Pp. 877. Price 21*. net. 

WnETHER it is that we are pygmies compared with our 
forefathers, or that collectivism is in the air, or simply that a 
multitude of authors provide so many separate centres of 

HO The lancet,] 


[Jan. 11,1908. 

infection, if we may bo term them, for the Bale of a book, 
certain it is that the tpivos or contribution feast is now 
popular in medical literature rather than the banquet pro¬ 
vided by the mature experience of a single author. The 
Index before us is the work of 72 contributors and, amid 
such a multitude, we cannot but admire the modesty 
of the surgical editor who has apparently made no con¬ 
tributions to the text but has contented himself with super¬ 
visory work. The book deals with medicine, surgery, and 
speoial subjects and so far as it is possible to comprise the 
treatment of all ailments to which flesh is heir in 
a single volume the result is satisfactory. The articles 
are clear and to the point and “ care has been taken to avoid 
embarrassing the reader with a large choice of procedures.” 
The book should prove useful to the practitioner in the course 
■of his everyday work. The impossibility of separating treat¬ 
ment from questions of diagnosis and pathology is illustrated 
In this Index, and here and there the editors have been 
nnable to refrain from sections dealing summarily with these 
subjects. It has also apparently been thought necessary 
to add an index, which is rather a confession of failure 
In the original arrangement. The supplementary index 
■contains a good many examples of how not to do it. 
Such entries as “Incision, its use in empyema,” “Danger, 
■Condition of, in Anaesthesia,” serve as examples. We 
may add that “Achoria” can only mean inability to 
dance, the treatment for which would presumably be 
different from that for “ acoria ” (dxopfa), failure of the sense 
of satiety. The printing of the book is good, the type 
employed being clear though necessarily close, while mis¬ 
prints are rare. The illustrations are also useful and are 
adequate in number. 


Light and A' Ray Treatment of Skin Diseases. By Malcolm 
A. Morris, F.R.C.S. Edin., Dermatologist to King Edward 
VII.’s Hospital for Officers, Surgeon to the Skin Department 
of the Seamen’s Hospital, Consulting Surgeon to the Skin 
Department of St. Mary's Hospital; and S. Ernest Dore, 
M.D. Cantab., Assistant in the Skin Department of the 
Middlesex Hospital. With 12 plates. London, Paris, New 
York, Toronto, and Melbourne : Cassell and Company, 
Limited. 1907. Pp. 172. Price 5i.—This is one of a 
series called “Modern Methods of Treatment” which is 
being issued by Messrs. Cassell and Company. In recent 
years many new methods of treatment have been introduced 
and there is a demand for more detailed accounts of them 
than those to be found in the ordinary text-books. Espe¬ 
cially is there a need for a fall description of radiant 
methods of treatment of diseases of the skin. Most medical 
men have very vague ideas of FinBen light and x rays and 
they would like to know more even if they have no intention 
of practising these methods. Sir Malcolm Morris and Dr. 
Dore are well qualified to speak with authority in these 
matters, as they have both had much experience in 
the radiant methods, and the former was one of the 
earliest to employ Finsen light in this country. The book 
is not, and is not intended to be, exhaustive but it contains 
all the essentials. The authors are very satisfied with the 
x ray treatment of ring-worm, and though they use and 
appreciate Sabouraud’s “ pastilles ” to measure the intensity 
of the rays, yet they do not think it advisable to depend on 
them alone. The amperage of the primary current, the volume 
of the induced current, the spark-gap, the appearance of the 
tube and of the anode, and the time of exposure should all 
receive attention. 

Le Micro-organisme de la Syphilis, Ireponema Pallidum 
(,Sehaudinn ). Par le Dr. LKVY-BlNG, Chef de Laboratoire 
de Saint-Lazare, Lamest de la Faculty de Helecine. (The 
Micro organiemof Syphilis. By Dr. Levy-Bing.) With figures 

in the text and one chromo-lithographic plate. Paris : Octave 
Doin. 1907. Pp. 329. Price 5 francs.—The microbe first 
described by Sehaudinn is now accepted almoBt universally 
as the cause of syphilis. Many previous “discoveries” of 
the bacillus of syphilis have been made but time has always 
disproved the claims. The spirochsota pallida, as it was first 
called, or treponema pallidum as it is now known, is stained 
with a good deal of difficulty and it was not till the special 
stain was employed that it waB possible to see it. It is now of 
diagnostic value, at least so far as its presence is concerned ; 
if it is not found its absence may only be apparent and may 
be due to want of skill on the part of the examiner. This 
volume contains all that was known up to the moment of 
publication of the treponema pallidum. The microscopic 
technique is fully detailed and the natural history of the 
organism is discussed. Unfortunately, we cannot grow it on 
any of the media tried and so its life-history is as yet 
undetermined. An interesting chapter is that dealing with 
the action on the treponema of mercurial treatment. Some 
observers have found the organism present after some treat¬ 
ment but Dr. L6vy-Bing has shown that under careful 
mercurial treatment the treponema steadily diminishes in 
abundance as the treatment is continued. The book is very 
thorough and well deserves perusal by all interested in this 

Wit and Humour of the Physician. By F. R. London: 
Alexander Moring. 1907. Fp. 218. Price Is. 6 d .—This little 
book contains an abundance of medical anecdotes, quips and 
cranks, and if they are not all likely to be greeted by 
“wreathed smiles” yet there is a sufficiency of amuse¬ 
ment in them to justify their title. The way to enjoy a book 
of this kind is to take it in small doses ; if many pages be 
ingested at one gulp they are liable to cloy. We are a little 
tired of the many variants of the old theme which jocularly 
accuses the doctor of being the immediate cause of a sick 
man’s demise or a fee-lover above other men. The book may 
be useful to after-dinner speakers at professional gatherings 
who have not the natural means of leavening their wisdom. 

The Poems of Samuel Taylor Coleridge. With an intro¬ 
duction by A. T. Quiller-Couch. The Three Clerks. By 
Anthony Trollope. With an introduction by W. 
Teignmouth Shore. The Life of John Sterling. By 
Thomas Carlyle. With an introduction by W. Hale 
White. Margaret Catohpole. By Richard Cobbold, with 
an introduction by Clement Shorter. The World's 
Classics Series. London: Henry Frowde. 1907. Price 
Is. each .—Sesame and Lilies and Ethios of the Dust. 
By John Ruskin. London: George Allen. 1907. Price 
Is. net.—The World’s Classics continue to stream from 
Mr. Frowde’s press with a regularity that seems to 
bespeak a solid appreciation on the part of the reading 
public. Every batch which we receive serves to remind us 
of the richness of true English literature. It is not the 
function of a medical paper to review critically the substance 
of such reprints as these, and indeed in the case of many 
there is hardly any new thing to be said. Coleridge has cer¬ 
tainly found his level as one on whom the fire from Heaven 
descended in his youth but whose flame was wofully 
quenched by profitless metaphysical self-torture in his 
riper years. But whilst poetry lives, “The Ancient Mariner” 
and “ Kubla Khan ” will retain to the full their mystic force. 
Two of the lesser known works of Carlyle and Trollope come 
next before us, the one an earnest apologia, the other a novel 
written only to amuse, and both with the stamp of a bygone 
day upon them. We take it that the introduction to “John 
Sterling ” by W. Hale White is not written by the physician 
of that name but by the able author of ‘ 1 Mark Rutherford’s 
Deliverance ” who now employs the name of his hero as a 
literary pseudonym. Mr. Teignmouth Shore’s introduction 
to “The Three Clerks” is delightful. The remaining novel 

Thu lanokt,] 


[Jan. 11, 1908. Ill 

of Mr. Frowde’s batch is a well-known Suffolk story of the 
barbarous penal code which prevailed in the eighteenth 
century. The last book of which we write, though of almost 
similar format, is from Mr. Allen’s press at the house which 
bears the name of the author of “Sesame and Lilies” and 
“Ethics of the Dust.” In spite of Raskins well-known 
desire that his books should be sold at “an entirely jest 
.price,” which meant more than the members of the work¬ 
ing classes were usually prepared to give to obtain them, 
yet we welcome the wider dissemination of his teaching 
by the lowering of its market value. No author could surely 
wish to put a bound to the knowledge of such a notable 
saying as this, that a book is written because “the author 
has something to say which he perceives to be true and 
useful or helpfully beautiful. So far as he knows no one has 
yet said it; so far as he knows no one else can say it. He is 
bound to say it, clearly and melodiously if he may, clearly at 
all events,” and so on to the rest of that noble passage. 
Think what we may of Raskin's ideals and illusions, his 
almost painful sense of justice or his lack of balance, we 
must ever be grateful for such beautiful thoughts as abound 
in “ Sesame and Lilies,” “The Crown of Wild Olive,” and 
many other of his writings. It is also a real pleasure to 
renew acquaintance in this volume with his charming idyll of 
the crystals which certainly did not receive the recognition 
that it deserved when first it was published. We hope to see 
before long all of Raskin’s works issued in series with this 
volume, on the production of which we congratulate his 

The Maternity Nurse's Daily Guide or Pocket Book of 
Reference. By Gkrtruije C. Marks, Certificated, Obstetrical 
Society of London. London :Bailli&re, Tindall, and Cox. 1907. 
Pp. 112. Price lr. 6 d. net.—Miss Marks describes her book as 
containing clear and concise directions as to the duties and 
responsibilities of a maternity nurse from the time of her 
engagement to nurse a patient until the completion of the 
case, and we are able fully to endorse her claim. Not only do 
the material duties of the maternity nurse receive clear con. 
sideration but a few sentences upon the tactful manage, 
ment of cases prove that Miss Marks is fully appreciative 
of one of the most important elements that make 
for success in her calling. Another praiseworthy feature 
of the book is that, with one exception, it draws 
a clear and authoritative distinction between the spheres 
of duty of nurse and medical man ; the exception 
occurs on p. 32, Section 86, where the nurse is directed to 
remove the placenta from the uterus manually if it be not 
expelled within an hour. In the case of urgent post-partum 
haemorrhage, such as is considered on p. 89, this might well 
be the right course for her to adopt but in the absence of 
urgency we consider that a medical man should be 
summoned to effect the removal, for the nurse’s protection no 
less than the patient’s. The list of “ necessary articles for 
the mother ” is a little long but certainly they are all 
desirable. We venture to think that this book will prove 
especially useful to midwives who were practising before 
the recent Act was passed ; it is conveniently small and 

Eossjeld's Polyglot Correspondent. London : Hirschfeld 
Brothers, Limited. 1907. Pp. 461. Price 3*. 6 d. net.— 
The intention of this little book, which will fit into the 
pocket, is that “any mercantile letter may be composed in 
either English, French, German, or Spanish by the simple 
method of combining sentences selected from the pages of 
the work.” It also contains a vocabulary of technical 
expressions and business words in everyday use. A book 
constructed on these lines is likely to be very useful to the 
Englishman who has to compose a letter in a hurry in any of 
the foreign languages mentioned and this little book should 
be of some assistance, but we think it needs careful 
revision as we have detected several errors in turning 

over its pages. For instance, on p. 63 we see “plustdt 
for “plus tot”; on p. 71, “ Wicderholte ” instead of 
“ wiederholte ” ; on p. 86, “ erhaltei ch ” instead of “ erhalte 
ich”; on p. 83, “SeinSie” instead of “ Seien Sie”; on 
p. 123, "ton” for “ tous ” ; on p. 182, “ hdehsten ” for 
“hoohsten”; on p. 232, "ordrez”for "ordres”; on p. 347, 
“ ing ” or “ inq ” for “cinq”; on p. 359, “camphore” for 
“camphor”; and on the same page "capres” instead of 
“capers. On p. 361, "Chartreuse liquor ” is not usual. On 
p. 436, for "bill of lading” we miss the familiar “con- 
naissement.” On p. 441, “roue dentde” is hardly “dented 
wheel,” but should be toothed-wheel or cog-wheel; and on 
the same page “ marchand de comestibles ” is hardly “dealer 
in eatables,” but ought to be “provision merchant" in 
English. On p. 442, “Down the river” is translated into 
French by “Amont,” but “amont” means “up the river.” 
“ En aval ” is the French for “ down the river.” On p. 446 
the expression “ mark of a coin ” is hardly what is meant, 
we think. Should it not be “ mint-mark ” ? 

Hindustani Grammar Self-Taught. In four parts : 1. A. 
Simplified Grammar ; 2. Exercises and Examination Papers ; 
3. The Vernacular; 4. Key and English-Hindustani Dic¬ 
tionary. By Captain C. A. Thimm. Second edition. Revised 
by Shams’ul ’Ulama Sayyid ’Ali Bilgrami, M.A. Cantab., 
LL.B., Assoc. R.S.M. London, M.R.A.S. London : Marl¬ 
borough and Co. 1907. Pp. 120. Price, wrapper, 2s. ; 
cloth, 2s. 6d.— This is an attempt to teach Hindustani by 
means of the Roman character and the attempt has been 
successful. It is not, of course, possible to transliterate 
exactly the Hindustani words but much has been done to 
facilitate the acquirement of the colloquial language. Many 
Europeans find great difficulty in reading the Arabic 
character in which Hindustani is uaually written and there¬ 
fore the Romanisation is useful. The Arabic character is, 
however, taught to some extent and reading exercises are 
given and there is one page in Hindustani script. A few 
examination papers are answered. This little book is really 
wonderfully complete for its size. 


Clinical Studies: A Quarterly Journal of Clinical Medicine. 
By Byrom Bramwell, M.D. Edin., F.R.O.P. Edin., F.R.S. 
Edin., Physician to the Edinburgh Royal Infirmary. VoL V. 
With 90 illustrations. Edinburgh: R. and R. Clark, Limited. 
1907. Pp. 413.—Some very interesting lectures and reports of 
cases are published in this volume of “ Clinical Studies. A 
lecture on the Process of Compensation and Some of its 
Bearings on Prognosis and Treatment is well worth 
careful perusal. Dr. Bramwell points oat that the com¬ 
pleteness of compensation depends upon several factors, 
the most important of which are: (1) the amount 

of the reserve ; (2) the suddenness and extent of the 
call: whether sufficient time is allowed for the realisa¬ 
tion or development of the reserve is obviously a most im¬ 
portant point; and (3) whether the demand for compensa¬ 
tion is temporary or continuous, in other words, whether the 
lesion is stationary or progressive. He then proceeds to 
apply these statements to compensation in lesions of the 
brain. His remarks on compensation in valvular affections 
of the heart will be found most interesting and sug¬ 
gestive. He directs attention to the conditions that are 
necessary for the production and maintenance of a sufficient 
and satisfactory muscular hypertrophy—the muscular tissue 
must be sufficiently healthy to become hypertrophied. It is 
evident that when myocardial degeneration is present to 
any extent hypertrophy can never be quite satisfactory. 
The cardiac muscle must receive a sufficient supply of 
healthy blood and the waste products of its combustion 
must be sufficiently quickly removed. Finally, the trophic 
nerve apparatus must be in a healthy condition. These 


[Jan. 11,1908. 

various points have an important bearing when prognosis 
has to be considered. A clinical lecture on the preven¬ 
tion o! Pulmonary Tuberculosis will also be found 
interesting. In speaking of the infectivity of the 
disease Dr. Bramwell is careful to emphasise the fact 
that all cases of ‘‘phthisis” are not infective. In order that 
danger of infection may arise tubercle bacilli must be found 
in the sputum. Dr. Bramwell supports the imposition of 
compulsory notification of tuberculosis and details the 
measures which he considers necessary for the prevention of 
the spread of infection. We cannot altogether agree with 
the elaborate machinery which he wishes to set in motion to 
complete the logical sequence of compulsory notification 
but we do thoroughly endorse his wishes that each medical 
practitioner “ should become a missionary for the diffusion of 
knowledge regarding the nature of phthisis and the means 
by which it should be prevented.” 

Caledonian Medical Journal .—The first article in the 
January number of the Caledonian Medical Journal is by 
Dr. W. A. Mackintosh of Stirling, being a continuation of his 
account of an ancient Gaelic medical manuscript. Colonel 
Kenneth Macleod, I.M.S., writes on Medical Education in 
India. A description of a journey from London to Gibraltar 
on the P. and O. steamer Rome suggests the reflection that it 
deserves to be read by those who are familar with Henry Field¬ 
ing's “ Voyage to Lisbon.” Fieldiugwent to Lisbon in 1754 ; 
the route of the two vessels was, or at least might have been, 
exactly the same, for part of Lisbon was faintl